Penis Size and the Primitive State of Sexual Consciousness

On the Nature blog this week, there was a summary of an article originally posted in Proceedings of the National Academy of Sciences (PNAS) on the implications of penis size preference and evolutionary pressure for large penises.  If true that may explain why humans have the largest penis size of all primates.  Someone has apparently already figured out that male genitalia were the earliest developed physical traits in the animal kingdom.

In the experiment, researchers showed computer generated life sized projections of 53 frontal images of men of varying heights, flaccid penis size, and body type to a group of 105 heterosexual Australian women.  The women looked at the images and rated them for sexual attractiveness.   Since the original article is not accessible, the results on the Nature blog state that that a range of flaccid penis sizes and male body types were rated the most attractive.  At some point masculine body type (greater shoulder width to hip width) was more important.  There was not a direct correlation with penis size and attractiveness.  The graph of size versus attractiveness was described as an inverted U-shaped curve with attractiveness falling off at both extremes.  There were some remarks on the importance of this finding not the least of which that studies like this may make it easier to talk about an “uncomfortable subject”.  I doubt that the press will take such a nuanced approached.

As I read that last line, I thought about penis references in the popular culture over the course of my lifetime from Woody Allen films to Seinfeld episodes to morning radio shock jocks.  I have gone through the “sexual revolution” and noticed that very little has changed.  If anything the landscape seems to have shifted to a more male dominated perspective with the further objectification of women and much easier access to that content.  In some of that content there is a disturbing portrayal of serial violence (usually homicide) and sadomasochism even in prime time television.  All it takes is showing an MALSV (mature audiences, strong language, sexual situations, violence) disclaimer at the outset to broadcast a blend of sexual violence and gratuitous nudity.  The focus from business interests is producing as much of this content as possible combined with the legitimization of the pornography industry.  What is driving all of this?

There are two areas relevant to psychiatry that are the object of very little research and they are sex addiction and sexual consciousness.  Consciousness in general has not been much of a focus by psychiatry since the advent of DSM atheoretical descriptors that in effect limited the focus of study to extremes of human behavior.   The consciousness that I am referring to is the unique conscious state of individuals.  The current diagnostic system does not presume to diagnose individuals

Sexual addiction and other "behavioral addictions" like eating and gambling are all the rage right now.  The neurobiological theories of reward, initial impulse control involving positive positive reinforcement, and subsequent compulsive behavior based on negative reinforcement are thought to apply in traditional chemical addictions but can the same models apply to sexual behavior?  The problem is that there are vast uncharted areas connected to the midbrain and basal forebrain structures that are thought to be substrates for addictive behavior.  Not all of the details of neurotransmission within the system are known even though we have several cartoon versions.  An analysis from reference 3  suggests in a rat model of sucrose self administration that up to 28 regulatory proteins in various cell structures may form the basis for the signaling involved.  Despite several papers suggesting that behavioral and chemical addictions may have the same substrates, I have not seen any compelling evidence that this might be true.  If sex can be addicting, what are the risks of exposure and can we help people with serious problems involving their sexual behavior? 

The state of consciousness in psychiatry these days is at an all time low.  Biological reductionism and a poor understanding of the importance of modern psychoanalysis in exploring unique conscious states may be part of the problem.  The other part of the problem is a single minded focus on problems with human behavior that are clearly two standard deviations from the norm.  This basically leaves out the unique conscious state of the individual and the fact that many people are clearly affected by problems that can't be reduced to a psychopathological model.  Human sexual behavior and all of the behaviors it is associated with are excellent examples at both an individual and cultural level.   Those authors who have taken on this task; most notably the late Ethel Person, MD have described a continuum of male sexual fantasy and behavior from the perspective of psychoanalytic theory and treatment of associated problems.   One of the more interesting considerations to me is the omission of practically all considerations of fantasy and daydreaming in the DSM as if these important functions have no explanation and are not as grounded in prefrontal cortex as the working memory is.  Do we know the basic differences in the sexual consciousness of men and women?  Not from anything that I can find.

These considerations are as important for culture as they are for psychiatry and psychiatric research.  The current cultural attitude seems to be that we need a mechanical understanding of sex.  It is the mechanical approach that is presented as sex education in school.  Here are the parts, here is how they work, here is how you get pregnant, and here is how you get diseases.  No relevant discussion about associated emotions, human attachment, desire, or love.  No appreciation of scientific differences in the sexes.  No discussion about how the really big organ in the head is orchestrating everything.  Figuring out how to address these important issues is a lot more complicated than voting on the most attractive present day penis. 

George Dawson, MD, DFAPA

1.  Nuzzo R.  Bigger not always better for penis size.  Nature News April 8, 2013.

2.  Mautz BS, Wong BBM, Peters RA, Jennions MD. Penis size interacts with body shape and height to influence male attractiveness.  Proc. Natl Acad. Sci. USA http://www.pnas.org/cgi/doi/10.1073/pnas.1219361110 (2013). 

3.  Van den Oever MC, Spijker S, Li KW, Jiménez CR, et al. A Proteomics Approach to Identify Long-Term Molecular Changes in Rat Medial Prefrontal Cortex Resulting from Sucrose Self-Administration.  Journal of Proteome Research 2006 5 (1), 147-154

4.  Ethel Spector Person, MD.  The Sexual Century.  Yale University Press, New Haven, 1999.

Bipartisan Agreement on Treating Mental Illness - Believe It when You See It

The New York Times has an incredibly naive article on how legislators may be split on gun control but both parties support better care for people with mental illnesses. The article alludes to a bipartisan plan that would "prevent killers .....from slipping through the cracks."  The next paragraph says that the plan: "would lead to some of the most significant advancements in years in treating mental illness and address a problem that people on both sides of the issue agree is a root cause of gun rampages."

That would be groundbreaking news if it were true, but let's be realistic.  The history of funding treatment for addictions and mental illnesses in this country has been a downhill spiral for at least 30 years and there are no real signs that will changed.    Congress has essentially been at the root of the problem.  Congress after all is responsible for the disproportionately poor level of funding for the treatment of mental illness.  Congress basically invented the managed care and pharmacy benefit manager industry that has increased the rationing of psychiatric services that has led to the current deterioration.  Rather than focus of providing quality in the services that federal, state, and local governments typically provide (like community mental health centers, case management, civil commitment, protective services, and crisis intervention) they have adopted the managed care model of rationing services.

The only relative bright spot in mental health legislation was a parity law spearheaded by Senators Wellstone and Domenici.  The actual boilerplate is one thing and there was always a question about managed care would react to the parity law and if they could continue their successful rationing techniques.  Events in the past week suggest that they are as evidenced by the New York State Psychiatric Association and the Connecticut Psychiatric Society joining in a class action lawsuit against United Health Care and Anthem Health Plans for violations of the Mental Health Parity and Addiction Equity Act (MHPAEA).  The interesting aspect of the alleged "violations" is that they are standard rationing tactics that have been used by this industry for decades.

There are surprisingly few details of "improved mental health care" provided in this article.  There are many legislative tricks to make it seem like something has happened when it really has not.  The mental health issue seems like a safe haven for legislators who don't really want to address the gun issue.  I have posted some of the rhetoric on the issue here and some of it is fairly grim.  The President's initiative in the article involves over $100 million for screening.  There is no good evidence that screening adds much more than getting people on medications as fast as possible - probably too many people.

A related issue with Congressional lawmaking is that they rarely seem to consult anyone with expertise.  Many consider themselves to be experts in something even though they have never trained or worked in the field.  The people with the most significant access are business lobbyists and in many cases they are writing the laws or at least very satisfied with what is happening.  The focus is generally on improving the wealth of the folks with the lobbyists.  That is unfortunate because there are numerous ways to improve the provision of psychiatric services for severe mental illness without giving away more money to managed care companies.  The idea that "the most significant advancements in years in treating mental illness" will come out of Congress and business lobbyists sets my teeth on edge.


George Dawson, MD, DFAPA

Jeremy W. Peters.  In Gun Debate No Rift On Care for the Mentally Ill.  New York Times April 12, 2013.

The “Spike” in ADHD diagnoses

There was the usual furor in the press earlier this week about a CDC Study that suggested that ADHD diagnoses have spiked up to 11%.  A previous post on this blog suggests that the real prevalence of ADHD is closer to 6-8%.  The  press predictably implicates overdiagnosis, overprescribing, a Big Pharma based culture that suggests there is a pill for everything, and of course the DSM5 – even though it has not yet been released.  What is really going on?

Before getting into my theories let me express my profound disappointment in the Centers for Disease Control (CDC).  As far as I can tell they have no actual research document on this issue, at least they did not sent me that document or link when I requested it.  The closest I can come is the web page that suggests that it may contain the data.  You can find for example – the full text of the survey that was used for this data.  If you are interested in that actual data that lists several data files that require specialty software.  So we apparently have a “scoop” by the New York Times based on getting and analyzing the data files and other interested people (like me) do not have access to the original data.  That is really not acceptable for a government funded agency.  If I am wrong here – please send me the link or the raw data, but I am very clear that the CDC did not respond to my direct request for clarification and they always have in the past.

Rather than debate the limitations of the study which is not possible because there apparently is no published version of the study, the easiest thing to do is accept that the increase is diagnoses as estimated by surveys is in fact true and go from there.  When I think about drugs that are truly overprescribed by comparison, the first class that comes to mind is antibiotics.  This trend is so well known that the CDC has run a campaign about it since 1995.  There is some consensus that progress has been made but a recent commentary describes the overall effort as a failure with antibiotic overuse as high as 50-100% in some areas and suggests a comprehensive strategy.  The table below highlights a few problems especially with regard to treating infections caused by viruses with antibiotics in the past two years.

Problem	Findings	Reference
Acute sinusitis 3 million outpatient visits/yr in US	Antibiotics prescribed in 83% of visits 50% of patient diagnosed received a macrolide or quinolone and only 20% received amoxicillin – the recommended drug	Fairlie T, Shapiro DJ, Hersh AL, Hicks LA. National Trends in Visit Rates and Antibiotic Prescribing for Adults With Acute Sinusitis.Arch Intern Med. 2012;172(19):1513-1514.
Acute Strep Pharyngitis	56% received an antibiotic and only 19.5% had a confirmed diagnosis	Nakhoul GN, Hickner J. Management of Adults with Acute Streptococcal Pharyngitis: Minimal Value for Backup Strep Testing and Overuse of Antibiotics. J Gen Intern Med. 2012 Oct 6.
Febrile Respiratory Illness (AFI)	The context (number of cases recently seen and pandemic status) affected whether or not physicians prescribe antibiotics for AFI.	Courtney Hebert, Jennifer Beaumont, Gene Schwartz, Ari Robicsek; The Influence of Context on Antimicrobial Prescribing for Febrile Respiratory IllnessA Cohort Study. Annals of Internal Medicine. 2012 Aug;157(3):160-169.
Unnecessary fluroquinolone use in hospitalized patients	39% of fluroquinolone use was unnecessary as defined as excessive duration of therapy or use for non bacterial infection.	Werner NL, Hecker MT, Sethi AK, Donskey CJ. Unnecessary use of fluoroquinolone antibiotics in hospitalized patients. BMC Infect Dis. 2011 Jul 5;11:187. doi: 10.1186/1471-2334-11-187.

A direct comparison of antibiotic over prescription and the possible over prescription of stimulants is instructive from several perspectives.  It may not be obvious but a clinician faced with whether or not a patient has a bacterial infection or whether they have ADHD has similar problems.  In both cases, the therapy may precede the diagnosis.  By that I mean it is often impossible on purely clinical grounds to determine whether an infection is caused by bacteria or the patient's behavioral or cognitive complaints are cause by ADHD.  If at the end of an assessment the physician comes to the conclusion of bacterial infection or ADHD a medication is prescribed.  Nobody makes a probability statement and there is often the element of an “empirical trial” – if the patient improves the treatment and the diagnosis were correct.   Since any misdiagnosed viral infections will usually improve and most people given stimulants will experience cognitive enhancement whether they have ADHD or not – the empirical trial is a highly flawed approach but one of many biases in an area of diagnostic uncertainty.

Another issue is the expectations of the patient.  Pediatricians often face irate parents if they don’t prescribe antibiotics for certain infections that are likely to be viral.  Internists and family physicians face the same problem explaining why acute bronchitis generally does not require antibiotic therapy.  Patients often have stories about multiple antibiotic failures to treat their bronchitis when it is likely that the process was viral and happened to resolve on its own after the most recent antibiotic trial.  Many patients taking stimulants for no clear reason have similar reactions when their use of stimulants is questioned.

There is the issue of complications of both therapies.  I do think that the potential harm of antibiotic overprescribing far exceeds the harm of stimulant overprescribing and that is the basis for the CDC having an initiative in this area for nearly 20 years.  On the basis of acute complications and medical side effects stimulant medications are some of the safest around.  On the other hand, I have also treated stimulant abusers who were routinely taking several times the recommended dose for years or who went on to use cocaine or other stimulants regularly and had the expected complications from addiction.

An important area of divergence between these classes of prescription drugs is the potential for addiction with stimulant medications and the new cultural movement that has been described as “cognitive enhancement”.  Both of these factors add the dimension that patients can misrepresent themselves to physicians with the intent of getting a stimulant prescription.  That does not happen with antibiotics, but the scope of the problem in terms of which drug is overprescribed more seems decidedly in favor of antibiotics at this time.  That does not bode well for the potential for even higher rates of stimulant overutilization in the future and in fact it seems obvious to me that there is no reason why it would not rise to at least the same level of antibiotics.

The reaction to these parallel problems in the press is instructive.  Rather than seeing the possible over prescription of medications as a problem inherent in the practice of medicine (like antibitotics) – a common reaction in the press is that this is a problem with over diagnosis and leaps to suggesting that the unreleased DSM5 will lead to even more diagnoses.  They quote several experts who respond strictly on the issue of whether the numbers are “real” or not.  The Director of the CDC – Thomas R. Frieden, MD makes an accurate comparison of the problem to both antibiotics and pain medications but concludes:  “The right medications for A.D.H.D., given to the right people, can make a huge difference. Unfortunately, misuse appears to be growing at an alarming rate.”  Clear diagnostic criteria for bacterial infections has not been the solution nearly 20 years of antibiotic over prescribing.  From what we know about trends in overprescribing, I would expect stimulant prescriptions to continue to increase irrespective of the release of the DSM5.  It will prove to be an easy scapegoat for a poorly understood problem.

The unfortunate focus of the New York Times article is the familiar: “Are drugs good or bad?”  The appropriate focus for physicians is focusing on the process and how individual and group practices can be modified to reduce overprescribing.  In most cases that would involve four additional steps – a discussion of cognitive enhancement and why it is not a good idea, screening for an addiction diagnosis, making sure that there is a clear level of functional impairment, and urine toxicology.  The effects of an assembly line approach to managing physicians and inadequate time for complex diagnostic thinking cannot be minimized.  A central collaborative model used by the University of Wisconsin for the diagnosis and treatment of dementia could be adapted to a network of clinics to treat ADHD.  This could provide the best solution to practice drift and provide clear markers for uniform prescribing.

George Dawson, MD, DFAPA

Allen Schwartz, Sarah Cohen.  ADHD Seen in 11% of US Children as Diagnoses Rise.  NYTimes March 31, 2013.

Merikangas KR, He J, Rapoport J, Vitiello B, Olfson M. Medication Use in US Youth With Mental Disorders. JAMA Pediatr.2013;167(2):141-148. doi:10.1001/jamapediatrics.2013.431.

Rubin D. Conflicting Data on Psychotropic Use by Children: Two Pieces to the Same Puzzle. JAMA Pediatr. 2013;167(2):189-190. doi:10.1001/jamapediatrics.2013.433.

Fairlie T, Shapiro DJ, Hersh AL, Hicks LA. National Trends in Visit Rates and Antibiotic Prescribing for Adults With Acute Sinusitis.  Arch Intern Med. 2012;172(19):1513-1514. doi:10.1001/archinternmed.2012.4089

Gonzales R, Ackerman S, Handley M. Can Implementation Science Help to Overcome Challenges in Translating Judicious Antibiotic Use Into Practice?: Comment on “National Trends in Visit Rates and Antibiotic Prescribing for Adults With Acute Sinusitis” and “Geographic Variation in Outpatient Antibiotic Prescribing Among Older Adults”. Arch Intern Med.2012;172(19):1471-1473. doi:10.1001/2013.jamainternmed.532

Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009 Aug 7;4:50. doi: 10.1186/1748-5908-4-50. PubMed PMID: 19664226; PubMed Central PMCID: PMC2736161.

Hebert C, Beaumont J, Schwartz G, Robicsek A. The influence of context on antimicrobial prescribing for febrile respiratory illness: a cohort study. Ann Intern Med. 2012 Aug 7;157(3):160-9. doi: 10.7326/0003-4819-157-3-201208070-00005. PubMed PMID: 22868833.

The Duty to Warn, Law Enforcement and the Public Health

The issue of reporting dangerousness to law enforcement was in the news this week with a story 2 days ago about the accused Colorado theater shooter James Holmes.  I happened to catch it on public radio where it was announced that NPR had been one of the news organizations who had petitioned the court for access to suppressed information about the psychiatrist’s role.  The New York Times story states that the psychiatrist – Dr. Lynne Fenton contacted campus police about Holmes' potential dangerousness and they deactivated his student ID and access to campus building.  Various sources state that he was threatening his psychiatrist by e-mail.  The new information is more detailed than an original article from the Denver Post on August 30, 2012.

In the original article Dr. Fenton testified that her physician-patient relationship with the patient ended on June 11.  At that appointment there are some reports that Holmes told Dr. Fenton that he fantasized about killing a lot of people.  The shooting occurred on July 20.   The newly unsealed documents show that the psychiatrist “told a police officer that her patient had confessed homicidal thoughts and was a danger to the public.”  The documents also show that the psychiatrist was being threatened by both e-mails and texts.  Dr. Fenton also advised the police officer that she was fulfilling her legal requirement by making the report to the police.  A related article states that police officer asked Dr. Fenton if she wanted the subject apprehended and placed on a 72 hour hold and she said that she did not.

In addition to the public health concern about homicide prevention, psychiatrists in this situation have a concern about the need to prevent their patients from harming others.  That forms the basis of at least one dimension of most state civil commitment laws.  Most state laws describe a duty to warn potential victims, but forensic psychiatry texts talk about more general responsibilities.  For example, Gutheil and Appelbaum state:

“Psychiatrists have always faced the potential of suits as a result of negligently allowing patients to be released or to escape from inpatient facilities when these patients later cause harm to others…” (p. 148)

In a typical outpatient setting, the modern duty to protect identifiable persons dates back to the Tarasoff case or Tarasoff v. Regents of the University of California.  In this case a psychologist was informed by his patient that he intended to kill a young woman.  The psychologist contacted campus police and advised them that the patient had schizophrenia and should be detained and committed.  The police temporarily detained the subject but he was released and several months later and killed the identified victim.   The courts found that there was a duty to warn the identified victim that superseded confidentiality.  I encourage anyone to read the details of the original review of the case to notice how negligence in this case passes from the mental health professionals to the police and back.  I think that there may be a more straightforward analysis and I would invite any evidence to the contrary.  My understanding is that the legal profession studies negligence from the perspective that there is no one who is free from responsibility.  In any complex activity like needing to report dangerousness, there will always be some sharing of responsibility if there is a bad outcome.  From a physicians perspective the probability of that happening increases with the presence of liability insurance.

On a personal level, occupational stress goes through the roof in situations like this.  Imagine that you are seeing patients in a clinic and trying to be as helpful as possible and you have just seen a person who you think is dangerous.  The situations is more complex if that patient has threatened a specific person, threatened you and your family, or brought a weapon into the clinic.  The first order of business is to try and calm down.  In some cases you may have colleagues available for consultation, but in many cases a psychiatrist is on their own.  The next step is figuring out whether you are in a situation that requires a duty to warn and what must be done to fulfill that obligation.  State statutes are complicated and not uniform.  In a recent review of state Tarasoff laws, the statutes of all 50 states and the District of Columbia were categorized into whether or not reporting was mandatory, discretionary, or no law at all. The definition of mandatory for this classification was a requirement to warn.  Discretionary allows for a breach of patient or client privileges for the purpose of warning.  Using this analysis 33 states have a mandatory duty, 11 states are discretionary and 7 states have no law.  Psychiatrists at this point may seek legal consultation due to the complexity of the situation and may still receive vague advice.  A good example is something along the lines of: “Well I would rather defend you for this rather than that.” – based on their preceding legal advice.  The first time I bumped up against that advice I realized that doctors were cannon fodder for the legal profession. 

The second critical point is the call to the police.  In both of the cases mentioned so far campus police were involved.  Are there courts where that would be questioned?  I don’t think that duty to warn laws specify any particular law enforcement.  Despite that lack of specificity, the police have widely variable capacities to respond to these calls.  The police can be notified and nothing can happen.  As illustrated in this post, the police can be notified and decide on their own that the patient is not dangerous and release them.  That also applies to what type of protection the police can offer potential victims.  I have seen the police go directly to a the person issuing the threats and tell them there will be clear legal problems if they do not stop to mailing a fax of a handgun receipt of transaction where the potential perpetrator who had already issued threats had acquired a handgun.  There is often a significant gap between any report to the police and palpable decrease in danger to those threatened.  In many cases an entire clinic is threatened and a safety plan needs to be put in place.  

The final consideration is whether the person needs an acute evaluation and emergency hospitalization for psychiatric assessment.  I have several previous posts giving my perspective on the issue of homicide prevention and how acute psychiatric treatment can prevent aggression and violence, but it takes a functional commitment court and facilities that have the expertise to provide this level of treatment.  Many decisions seem to be made based on existing resources rather than any absolute quality marker.  Should any person who is homicidal because of an acute psychiatric disorder not be hospitalized because the local community hospital does not treat aggressive individuals?  Should that decision be made on a decision by Medicare or the managed care industry on how many days of hospital care they will pay for?  Hospitalizations for these patients typically outrun the funding by 2 – 3 weeks.

Like all of the piecemeal approaches to involuntary treatment there is an easy fix.  I did not digress into the tremendous amount of stress these situations cause and how that stress can drag on for weeks to months.  If there is an adverse outcome the stress level is even worse.  What is needed is a clear pathway that maintains the boundary between law enforcement and psychiatry.  A uniform law implemented across the country should clearly say that a psychiatrist has a duty to report to law enforcement and at that point law enforcement has a duty to assess and potentially detain the person making the threat.  That would include transporting them to a hospital that does civil commitments for emergency treatment as necessary.  Law enforcement also needs to warn the potential victim and protect them.  Psychiatrists should have no duty to track down identified victims or apprehend or take threatening patients into custody.  That is clearly the purview of law enforcement.

The technical details of the interface between the law and psychiatry in the case of a threatening or potentially violent patient needs a great deal of improvement.  There are very few situations as stressful in the rest of medicine.  Some psychiatrists will encounter these situations only a few times in their career and others are immersed in aggression and violence.  Improving the approach will enhance assessment and treatment of the problem and also make it easier to recruit talented people to focus on the problem.

George Dawson, MD, DFAPA

Edwards, Griffin Sims, Database of State Tarasoff Laws (February 11, 2010). Available at SSRN: http://ssrn.com/abstract=1551505 or http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1551505

Gutheil TG, Appelbaum PS.  Clinical Handbook of Psychiatry and the Law.  Lippincott, Williams & Wilkins.  Phialdelphia (2000): p  148

A Primer on the Utilization Game

I want to post some references on the issue of "overutilization" but it is necessary to review the concept before I can post those references of make any further arguments about it.  Most people fail to understand that when they are talking about psychiatric practice in the US that it is tightly controlled by large health care and pharmaceutical middle men who make their profits to a large extent by denying care or insisting on cheaper care.  The very first articles using this term in medicine date back to the 1970s and involve policing various health care providers who were ordering unnecessary tests and procedures largely to prevent the loss of taxpayer dollars.  Some of the first articles looked at the problem as a combination of the need to assess quality of care according to certain standards, illegal behavior or intentional fraud, lack of education on the art of the practitioner, and "to ascertain where there is overutilization or underutilization of services perpetrated either by the practitioner or by the patient". 

In this early reference dental, optometry and podiatry services were an areas of focus and the measures of overutilization included too many x-rays, unnecessary fillings, unnecessary prescription of orthopedic shoes, and shorting prescriptions.  Professional services were evaluated by peer review and were categorized as being problematic because of unusual pattern of practice, poor quality of care,  unethical procedure, office facilities, qualifications for practice, abuse of billing codes, fraud, and self referral.  Although the source of the investigations and lack of equivalence of markers were problematic there ws a suggestion that overutilization was a significant problem.  Underutilization was suggested as a significant problem in under served populations but it was not systematically investigated.

The most systematic unbiased investigation of overutilization was done by the Peer Review Organizations in the late 1980s and early 1990s.  These efforts are documented to some extent in the National Academy of Sciences texts.  The protocol in the PROs consisted of a list of generic quality screens applied by nurse reviewers to hospital and clinic records.  The charts were also reviewed for appropriate utilization.  If a chart was flagged by a nurse reviewer it was sent to a physician reviewer for confirmation.  All physician reviewers were rigorously screened for qualifications and conflict of interest.  No reviewer could review records from any clinic or hospital that they were affiliated with.  Reviewers also had be in active practice and everyone knew that you could not make a living from reviewing charts for the PRO.

The result of the PRO experiment is a significant untold story.  A total of 6.3 million cases were reviewed using these protocols by 54 PROs across the country.  The denial rate for overutilization was 2.7%.  The frequency of quality problems was 1.3%.  The total cost of the program was about $300 million per year compared with the total cost of Medicare for the same year being $81.6 billion. I was a physician reviewer at the time and was eventually notified that the PRO program was being phased out because the cost of the program could not be justified by the amount of care denied ($300 million versus $220 million).  

What happens when overutilization is handled by companies that profit directly by denying care and the physician reviewers are either employees or contractors with that company?  As you might expect, the denial rate heads in a predictable direction.  Although it has not been extensively investigated, this article showed a denial rate of about 10% with rates varying with the companies involved.  As expected health plans with greater profit margins had higher denial rates and discounts.  Denial rates of 8-10% were replicated in another large study.  

At some point it became apparent to insurance companies that behavioral health services (their term for mental health and psychiatric services) would be an easy target for rationing and so-called "carveout" approaches.  This was buoyed by the Employee Retirement Income Security Act (ERISA).  ERISA effectively indemnified insurance companies and behavioral health plans against lawsuits over improper care.  Although there have been some suggestions that the courts may reconsider this indemnification, there has never been any significant movement in this area.  Managed care companies have successfully had their methods included in state statutes and have generally established a standard of care where rationing is a significant component.

A study by the Hay Group looked at the results of managed care rationing on mental health benefits as opposed to general medical benefits between 1988 and 1997.  There found a disproportionate decrease in mental health benefits across a number of parameters including:

- Fee for service plans were prevalent at the beginning of the study (92%) but they were largely replaced by managed care at the end of the study (20%)

- The value of general health care benefits decreased by 7.4% across the study but the value of behavioral health benefits decreased by 54.1%.

- As a total percentage of health care costs, behavioral health care decreased  from 6.1% in 1988 to 3.1% in 1997.

- Behavioral health care benefits were clearly rationed including a decreased number of inpatient days, a visit limit on outpatient care with per dollar visit limits and annual dollar limits that did not correct for inflation across the time of the study.

- Outpatient behavioral health care utilization decreased by 24.6%  between 1993 and 1996 while general health care utilization increased 27.4% in the same period.

- Inpatient mental health admissions decreased by 36.4% while general health admissions decreased by 12.7%.

The Hay Group Study was the best early evidence that mental health care was disproportionately rationed by managed care techniques.

If we fast forward to the present, managed care companies have taken the next step to make their rationing techniques as opaque as possible.  At some point some the largest companies have actually acquired the resources where health care is actually produced – clinics, hospitals, and groups of physician employees.   In that scenario they can bring their “overutilization” bias in house and use case managers to police doctors and tell them when to discharge patients.  The case managers are backed up by medical directors who are promoting the company line of a managed care company and who will do what they can to back up case managers if any physician is advocating for a longer length of stay.  They frequently have proprietary discharge guidelines that have not been scientifically validated that they use to establish discharge parameters.  It is no coincidence that the discharge dates all happen to be about the same time that most payers set as the maximum number of hospital days that they will pay for. 

The end result creates a health care system that is firmly entrenched to ration health care on the basis that there is an imaginary number of days or amount of money that can adequately treat a problem.  The only person who can advocate for the patient is their physician but he or she is clearly up against it.  The problem is more than being harassed by an outside company.  Now the physician’s job is on the line as well.  Disagreeing with the medical director on a consistent basis even a few times does not bode well for longevity within an organization.  In the case of hospital care we have physicians who realize that they need to discharge people in 4 or 5 days whether they have improved or not.  I can say from 22 years of inpatient experience that most people admitted to psychiatric hospitals with major psychiatric disorders do not improve to the point that they can be safely discharged in 4 or 5 days.  My conversations with outpatient physicians confirms this.  Typical managed care hospitals are no longer viewed as places where anything productive happens to improve patient stability.  The staff there will often admit it by saying that they are there for “mental health crises”.  But what happens when the crisis does not resolve in 4 or 5 days?

The limits on mental health care have also severely impacted outpatient care.  There is an emphasis on prescribing medication, often based on brief symptom checklists.  This also allows for the recruitment of large numbers of primary care physicians to treat problems once the checklist becomes the defacto mental health diagnosis.  Treating large numbers of people with anxiety and depression is much less expensive for health plans if the treatment is generic antidepressants or benzodiazepines.  Each patient is basically being “treated” for about $4/ month and they can be seen in follow up visits very infrequently.  It is well established in the research literature that different forms of psychotherapy work as well and in some cases better than medication for these conditions.  The research proven therapies generally require a specific course of treatment on the order of 8 – 20 sessions.  It is rare to see much therapy beyond three sessions in managed care settings and that would generally be received by a patient who was already taking a medication.

At this point we have devolved to a system of mental health care that devotes little time and effort to the treatment of mental disorders.  The treatment that does exist out there is clearly biased toward saving money for large health care companies who provide the bulk of it. All of that rationing is based on the premise that there is overutilization of services when the largest and best study shows that it does not approach the level of rationing that has occurred.

George Dawson, MD, DFAPA

1: Bellin LE, Kavaler F. Policing publicly funded health care for poor quality, overutilization, and fraud--the New York City Medicaid experience.  Am J Public Health Nations Health. 1970 May;60(5):811-20. PubMed PMID: 5462556; PubMed Central PMCID: PMC1348897
2: (1990) Medicare:A Strategy for Quality Assurance, Volume I: The National Academies Press.
3:  (1990) Medicare:A Strategy for Quality Assurance, Volume II: Sources and Methods: The National Academies Press.

4:  Hay Group: The Hay Group Study on Health Care Plan Design and Cost Trends, 1988 through 1997. National Association of Private Health Care Systems and National Alliance for the Mentally Ill, 1998.
5.  Dawson G.  The Utilization Review Hoax.  February 2012.

On the dangers of psychiatric diagnosis no longer being a process

I am inspired by a post on another blog having to do with the dangers of “premature psychiatric diagnosis”.  The author uses an anecdote to make a point about how a diagnosis of a psychotic disorder and then mismanagement of the treatment leads to a situation where there is no hope for the person affected.

From my perspective there are very few people with even severe psychiatric disorders who are hopeless.  In fact, people with some of the most severe cases of catatonia that I have treated became fully functional and were restored to their roles in their families and society.  That frequently occurred after months of inpatient treatment by a psychiatrist and staff who were interested and skilled in treating severe psychiatric disorders.  Much of what I did in 22 years of inpatient work was restoring hope and maintaining a hopeful atmosphere on my treatment team.

Diagnostic uncertainty is frequently cited as an area where mistakes are made.  Many studies document the medical comorbidity in patients with psychiatric disorders.  Despite anecdotal cases true medical causes of psychiatric disorders are rare.  I should qualify that by saying a brain disease, neurological or endocrine condition that is a direct cause for the psychiatric disorder is rare and I base that on screening patients and reviewing thousands of negative studies.  That said any acute care psychiatrist should know more about medicine and neurology than psychiatrists in outpatient settings because unlike their outpatient colleagues – they are responsible for making that determination.  On the psychiatric side, the potential list of causes of various syndromes is long and the actual diagnosis may not be evident until something happens on a long term basis.   A good example would be a drug induced psychosis.  In the ideal case, the patient is able to remain sober and any medical treatment for the associated syndrome can be tapered and discontinued.  In the real world, the chances of sobriety or even referral to a functional addiction treatment are low.

   

There are numerous limitations on psychiatrists.  The obvious one that practically all commentators leave out is managed care.  Is it reasonable to think that the diagnosis and treatment of any severe psychiatric problem like a psychotic disorder can be accomplished in 3 – 5 days?  That is the time frame that most managed care case managers are using to get people out of the hospital.  They often refer to purely proprietary guidelines on hospital lengths of stay that were clearly written by business people rather than clinicians.  I have been in the position of having a patient discharged by an administrator against my wishes so I know that it happens.  Managed care coercion is more subtle.  A managed care reviewer sitting at a desk in another state – reads chart notes and presumes to make a remote diagnosis and suggest that the person should leave the hospital.  They have no responsibility to the patient or their family.  Their only job is to get the patient out of the hospital to save the insurance company money.  Another constraint is at the level of public assistance.  Almost incredibly, many states link the availability of case management services to psychiatric diagnoses and they will clearly say in the statute that the person must have schizophrenia, major depression, bipolar disorder, schizoaffective disorder, or borderline personality disorder in order to qualify.  Having one of those diagnoses at discharge can be crucial to get housing and funded medical rather than be homeless.  That is a strong incentive to get the correct diagnosis sooner rather than later.

The work flow on inpatient units and in clinics is generally not considered.  If you have a psychiatrist seeing 12-15 inpatients and some outpatients and they are seeing 3 – 5 new patients a day that is not a lot of breathing room.  They will be (depending on other members of the team) able to collect collateral information from the family and outside sources, make direct behavioral observations, and relay treatment decisions and recommendations to the family.  In my experience occupational therapists, nurses, and social workers are all indispensable team members and often function in dual roles as a liaison with family members.  They can act as consultants to the family on legal and social issues as well as keeping them apprised of any changes in medical treatment on a day to day basis.

One of the key areas where care becomes fragmented both from a diagnostic and treatment standpoint is anytime there is a transition.  In terms of hospitals that occurs with any admission or discharge.  It also occurs between different outpatient clinics and between psychiatrists and primary care physicians.  I have been in situations where it took me two hours and calls to different physicians, pharmacies and relatives to reconcile a list of 10 medications.  At the end of that two hours I was still not absolutely certain of the patient’s correct medication list. 

The bottom line here is that good psychiatric diagnosis is a process. It is not like taking your car in to a mechanic and the mechanic plugging it in to an analyzer.  The best results occur when the patient and the family can communicate openly with the psychiatrist and any identified treatment team.  The diagnosis needs to take into account all of the available information and by definition it will only be as good as that information.   The critics of psychiatry always seem to think that this is a situation that is unique to psychiatric treatment.  As I have previously discussed it happens in all of medicine.  The basic difference being that many nonpsychiatric conditions lend themselves to analysis by a single observer.  There is something readily visible, audible or palpable that suggests an abnormality.  In psychiatry we are focused on communication, self report, and the observations of others.  We are also generally dealing with more information to make a diagnosis, especially if the patient’s capacity for self report is limited.  Psychiatrists more than anyone else need to be comfortable with diagnostic uncertainty and explaining these nuances to the patient and their family.

When the diagnosis is made it should be fully explainable to the patient and family.  Any stigma or negative reaction to the diagnosis should be discussed.  It should be evident that nobody is reducible to a psychiatric diagnosis given the fact that no two people are alike and each person is a unique individual with unique attributes.  This is true for any medical diagnosis and psychiatric diagnoses do not differ in that regard.   Nobody should leave the encounter with the idea that they are “hopeless”,  particularly in the case of a pure psychiatric diagnosis in the absence of a neurodegenerative disease.

I realize that most of us in one way or another are held hostage by a certain health plan, but if your psychiatrist or more probably your health plan does not follow that basic process – find a new one.  Getting stuck on whether or not a misdiagnosis has occurred without a plausible explanation for what has happened or continues to happen is generally not productive.  If you can’t get out of your health plan talk to the medical director and explain the deficiencies.  If that doesn’t work and you are concerned about the diagnostic and treatment process being rationed, contact your state insurance commissioner and file a complaint against the health plan.

Quality psychiatric care is possible, but it has been demonstrated that in many cases you have to fight for it.

George Dawson, MD. DFAPA

More on Homicide Prevention – LA County Style

I have been developing a theme of how to prevent homicide and mass killing for more than a decade.  As previously posted, I think that this needs to be done independent of the firearms issue with a public health focus on both primary and secondary prevention.  There have been a couple of developments recently that I would like to highlight and whether or not they are consistent with the public health approach.

The first is an article in the NY Times today on a unique approach to school threat assessment and intervention.  The article describes LA County’s School Threat Assessment Response Team.  Several threat scenarios are described that trigger a multidisciplinary response from team members representing law enforcement, school officials, and mental health.  The way the program is described it is unique in terms of engagement.  Threats at school generally result in one dimensional and fragmented approach to the problem.  The school has a protocol that may result in suspension.  Referral to mental health providers is frequently a limiting step due to the lack of appointments, insurance problems, or debate over whether the school system or the health care system is responsible for assessment and treatment.  This patchwork system is a set up for people with severe problems falling through the cracks.

The LA County response is for the team to make a rapid same day assessment at the point of the threat and at the student’s home including looking at their room.  How many times have we read about the marginal teenager who is thrown out of school for threatening behavior and they end up sitting in their room focused on the same thought patterns or watching other forms of violent activity on the Internet or in video games?  Getting right into that environment seems like a powerful intervention to me and one that is likely to yield better results.  The main reason for failure in situations where a threat has been identified is that lack of follow up.    People who are threatening and aggressive are not likely to care if they are thrown out of school and they are not likely to follow through with mental health interventions.  The response team also spends time educating people about how to communicate in emergency situations where there are many misunderstandings about confidentiality.

The LA approach is innovative and exactly what is needed to assess and intervene in crisis situations involving threats and dangerous behavior.  In situation after situation, tragedies occur when people people come to the attention of someone and there is no clear map for assessment and treatment.  That is true in the school system, in colleges and universities, in the workplace and in family situations.  I have personally talked with people who said that they either did not know what to do or they actively tried several resources and were told that there were no appointments available or that the person was not dangerous enough to treat and unless they agreed to a voluntary assessment and treatment that nothing could be done.  But it doesn’t stop at that point.  I am also aware of situations where there clearly was enough evidence that the person was dangerous enough to meet criteria for an emergency assessment but it was not done of the person was released for the emergency department.  In many of these cases there was an adverse outcome.  What is the problem?

There is a significant bias against aggressive and violent people.  To some extent that bias is self protective.  Any reasonable adult knows the obvious advantages of avoiding conflicts or even irrational behavior.  There are always plenty of stories in the news about the lack of Good Samaritans in situations where an aggressive act is being perpetrated in public.  Many psychological explanations of this behavior are offered but I think the obvious motivation is avoiding the conflict and possible injury.  That same code of silence often applies in cases where there have been sudden changes in behavior and the person involved has a treatable problem.  A second level of bias is the moralistic approach to aggressive and violent behavior that equates this behavior with bad moral conduct.  That applies in situations where criminals use aggression to intimidate people and get what they want.  It does not apply when the aggression is a symptom of mental illness.

The bias extends beyond members of the general public.  The health care system is activated by a legal concept called “dangerousness” or “imminent dangerousness”.  Every state has different statutory requirements and those statutes are interpreted on a highly variable basis across every county in the state.  In some counties it comes down to some of the public officials involved seeing themselves as protectors of people’s rights.  In other counties, assessment and treatment are more of a priority.  At the level of the health care system there is another layer of bias.  The overwhelming bias these days is that people should not be assessed or treated in a psychiatric facility for more than 4 or 5 days and any assessment or treatment should be kept to the bare minimum.  It is easy to find different clinicians make entirely different decisions when presented with the same potentially dangerous patient.  The end result is a patchwork of acute care settings where people can go for help.  Because of all the biases involved unless an aggressive act has been committed the likelihood of an intervention occurring is basically a coin toss.

That is why the LA County response is so important.  It is an intervention that activates a rational response to threats from people who are likely in distress and possibly mentally ill.  There is no dangerousness standard initially and that is a critical departure from the current nonsystem.  The goal of the LA County response is to engage the person and their social network and not make a one-time assessment and decide to admit or discharge the patient based on a dangerousness concept.  The LA County response is unique in that it is based on behavior and the goal is to help the person involved rather than decide on whether or not they should be committed.  The overall approach is very similar to community psychiatry case management teams except LA County teams seem to have more latitude because they are not limited initially by commitment standards.

The is an excellent approach to the problem and I hope that it is researched, expanded to mental health crisis teams and widely adopted if effective.  I don’t know why it would not be effective.

George Dawson, MD, DFAPA

Erica Goode.  Focusing on Violence Before It Happens.  NY Times March 14, 2003.