Pharmaphenalia

I've posted a fair amount about Big Pharma, and how they market drugs they know to be ineffective, or even unsafe, how they buy off doctors to be Key Opinion Leaders, or just active prescribers of their drugs.
And I've been smugly patting myself on the back for not using drug pens or post-its, etc. But not quite. When I meet with a new patient, I tend to take notes. And since I don't have a chart yet for that patient, I use a clipboard with plain, looseleaf paper. I don't pay much attention to the clipboard, because I've been using it so long I don't even notice it. How long? Since residency. I know this because it's a Zyprexa clipboard, and I haven't gotten stuff from drug reps since I was a resident.

Sorry for the crappy photo, but it's some pretty glaring advertising, no? I don't understand what the little dude at the bottom is supposed to symbolize.

Is it a big deal that I use a zyprexa clipboard? I don't know. I feel like I should be more cognizant of what it might mean to patients. Does it make them think I'm going to throw an antipsychotic at them? That I get lots of stuff from drug reps?

Regardless of what it means to my patients, I think there's something to the fact that it's insinuated itself so thoroughly into my work life that I don't notice it anymore. It seems broadly emblematic of the situation with drug companies. They're part of our thinking. They're just there, no questioning required. Of course I use a Zyprexa clipboard, who doesn't use all that cool, free stuff the drug reps give away?

I decided to make my own symbolic gesture, and get rid of it. But I do need a clipboard. I can probably dig up some old thing at home, but I thought I'd get a really fun clipboard, to make up for my loss.

And this is it:

the hold-tight

Lime Green Clipboard

From Poppin. Set me back all of $5, a small price to pay for ejecting Big Pharma from my office.

While I was at it, I decided to get some fun office stuff:

the cut-above

White Scissors

This pair will beat rock and paper every time.

the most-writeous

White Letter Size Writing Pads

the write-away

Bikini Medium Spiral Notebook

the always-on-point

White Retractable Gel Luxe Pen

The clipboard is simple and perfectly functional. The scissors work well and have white blades. The paper is dense and has a nice hand. The notebook is cheerful. And the pens are cool-looking but write scratchily.

And not only is Poppin not paying me to write this, but they don't even know I exist. Which is good, because that way they can't target their marketing at me, like the Lilly rep who gave me the Zyprexa clipboard.

Everyone's a Shrink

Here's a quick link to what I think is an important post by George Dawson, MD, at Real Psychiatry, on the difficulty many people have differentiating an innate understanding of people that most people possess, and the practice of psychiatrists, who have spent years training to understand things in a more rigorous way (I'm not even talking about analysts, here).

Is Bullshit A Better Term Than Antipsychiatry?

Please read it, it's important.

Red, Gold, and Green

Did you guys see this in the NYTimes?

Hospital Chain Said to Scheme to Inflate Bills

Every day the scorecards went up, where they could be seen by all of the hospital’s emergency room doctors.
Physicians hitting the target to admit at least half of the patients over 65 years old who entered the emergency department were color-coded green. The names of doctors who were close were yellow. Failing physicians were red
The scorecards, according to one whistle-blower lawsuit, were just one of the many ways that Health Management Associates, a for-profit hospital chain based in Naples, Fla., kept tabs on an internal strategy that regulators and others say was intended to increase admissions, regardless of whether a patient needed hospital care, and pressure the doctors who worked at the hospital.

There are 8 whistle-blower lawsuits in 6 states against HMA. They fired a woman for refusing to fire the doctors who wouldn't comply with the demand. They admitted an infant for a fever of 98.7. They didn't reveal to their shareholders that they were being sued until after the shareholders voted for them to merge with a larger hospital corporation. And the piddling little $10 million dollar fines they're being threatened with are so minuscule to these people that they might as well be threatened with ice cream for dinner.

I'm having such a party. There it is, black on white in the NYTimes. You wanna point fingers at wasted health care dollars? Maybe the doctors aren't the culprits you've imagined them to be. I'm surprised these are only whistle blower suits. There must have been some iatrogenic deaths.

Squished

I have one of those free subscriptions to magazines from some credit card points, and I don't even remember if I actually ordered a year of Real Simple, or if it was substituted for something else I ordered. I don't look at it much, but I got the February 2014 issue in the mail today, and as I was flipping through to "Roasted Salmon/Barley/Smoked Paprika/Fennel/Swiss Chard/Chickpeas/Basil/Scallions, which I will never have the time or energy to prepare, I noticed an article entitled, The Patient Will See You Now. It's about deciding whether or not to break up with your doctor. It includes some common sense recommendations-voice your concerns, ask what you can do to be seen on time, and so on. In the sidebar, it lists "5 Common Signs That You Need A Change".

1. You're doctor doesn't tailor recommendations to your life.
2. He's always running late.
3. She rushes you.
4. The office is disorganized.
5. She's arrogant.

And since Real Simple is a pretty mainstream publication, tailored more towards women, admittedly, I'm working on the assumption that it reflects what people want from their doctors-they want to be listened to, they want their doctor to spend enough time with them so they feel understood, they want their individual concerns addressed, they want a thorough exam which they seem to equate with time (in my experience, more related to the doctor's skill, but what do I know), and they want to be treated with respect.

None of this is unreasonable. Except.

The lead article in this month's Carlat Report, An Ethical Perspective on the Affordable Care Act, is about some of the ethical conundrums that will arise, if they haven't already, due to the vastly increased number of insured, as well as the other provisions of the ACA. I know a little something about this article because I wrote it. And I'm going on the record now to state that it was extremely difficult to write, mainly because the more I researched the topic, the more discouraged I got about the whole mess.

Allow me to quote:

Several innovations of the ACA are intended to incentivize doctors not only to provide better quality care, but better quality care at equal or lesser cost—in other words, greater value. However, since a goal of the ACA is universal access to health care, this means that doctors are expected to spend more time with more patients, while providing better care for each patient at a reduced cost.

(Note: I'm not allowed to post or otherwise publish the full article for, I think, six months, but I'm pretty sure one small quote is okay. So.)

See the problem? The ACA is convinced that its provisions will allow people to get better care from and spend more time with their doctors, but these same provisions make it impossible to do so. The American public is in for a serious disappointment.

Also today, I received the January 17, 2014 edition of Psychiatric News, and there, on page 4, is an article entitled, DB Helps Develop Tool Kit to Help Physicians Thrive in ACOs. The tool kit was released by the Toward Accountable Care Consortium of North Carolina, to help doctors organize into ACOs, where doctors and hospitals agree to work together to provide "better value" care, meaning higher quality at less cost, and "share in the savings" they generate. These can involve a collaborative care model, in which patients in a primary care setting are screened by their PCPs for psychiatric problems, and then referred to a care manager, often an MSW, who follows up. Psychiatrists supervise the care, but never see the patients. The quality of care in an ACO needs to be measured, to determine if it is both "quality" and cost efficient. This is done by the soon-to-be-not-officially-mandatory-but-you'll-be-penalized-financially-if-you-don't-do-it PQRS, for example, which involves a mind-boggling process, and "measures" that are just time-consuming and meaningless checkboxes.

Allow me to quote:

“This is the wave of the future,” [Bridges] said. “We are leaving fee for service for some kind of new payment system that rewards value, and I believe we are really on the cusp of a remarkable change in the way psychiatrists are going to be working.”


This is the ACA's definition of spending more time with patients and providing better care. And here we doctors are, trying simultaneously to satisfy the people who read Real Simple, and the provisions of the ACA.

After much consideration, I've come to the conclusion that the solution to all of this is obvious.

I need to stop reading.

The Rest of the Meeting

As much as I enjoy the annual APSaA meeting at the Waldorf, I find it exhausting. So I only have three more groups to write about, because that's all I could manage to get myself to.
.

D. W. Winnicott

1. A Winnicottian Approach to the Treatment of Children and Adults with Asperger’s Syndrome: The Psychic Impact of Neurological Difference

This was another case-based group, so I'll have to stick to theory. A member of the British "middle school" (that's halfway between the Kleinians and the Freudians), Winnicott was a quintessentially British pediatrician. He had a drawing game he would play, particularly with children, where he would begin a drawing, and the child would add something, and they'd take turns, until he got a sense of what was happening emotionally for the child. His intuition with patients was astonishing. In The Piggle, he writes about his treatment of a young girl who went by the nickname, "Piggle". Her family lived far from him, so there were long stretches when they weren't meeting regularly. After one of those periods, she came to his office, and as soon as he opened the door and looked at her, he knew, without being told, that she needed to be called by her real name from then on.
Winnicott's writing is a little strange. His style is clear, but his concepts are often paradoxical. He was the originator of the term and concept, "transitional object", which he describes as an object that exists somewhere between fantasy and reality:

...the third part of the life of a human being, a part that we cannot ignore, is an 
intermediate area of experiencing, to which inner reality and external life both contribute.

If you've never read the paper, link to it, above. It's worth the time and effort.

He also originated the concepts of the "good enough mother", and the "holding environment". It's this last that is relevant for the treatment of Aspergers, or Autism Spectrum ( a term I seriously dislike, for reasons I can't get into).

Basically, the mother (or whoever is in that role) creates a safe, controlled environment for the baby, using her affection, often physical, and empathy for containment. "Spectrum" babies have great difficulty tolerating that kind of interaction, which they experience as intrusive. So from the get-go, things are different for those babies.

The presentation was about coming at the treatment from this perspective, and a lot of the focus was on helping the patient deal with the anxiety that goes with interacting with the world, for those with Aspergers, including pharmacological.

Nuff said.

2. Facing the Facts: Self-Disclosure and the Analytic Relationship

This group dovetailed nicely with the one about  the Analyst's Experience of Loss and Death, but it had a very different feel to it. There was something going on with the group, or the presentation maybe, that created a different environment in the room, so that people were not particularly forthcoming with their own experiences surrounding self disclosure.
There's always the tension between how much one tells ones patients about oneself, and how much one withholds. And either side can constitute a technical error. One thing that's difficult for people to talk about is the degree of sadism that exists in withholding information from patients. It's hard to remain cognizant of that, and at the same time, remember that there are good technical reasons not to tell the patient much about oneself. And I think that discomfort played out in the group discussion.

3. Research in Psychoanalysis: Concepts and Methodology of Single Case Research: the On-Line Archive

I was really excited about this group, and unlike the psychotherapy training group, I was not disappointed.

I've been thinking about this for a while. The typical analytic paper involves an initial section about the general topic, say, perversion,  with some relevant literature referenced, followed by a case presentation, including process, and finally a discussion. So what you're talking about here is an "n of 1".
The thing is, there are a boatload of "n's of 1" out there, so why not combine them into something analogous to a meta-analysis.

Well, this is happening. And it's called a "Meta-Synthesis"(qualitative, rather than quantitative). A group from the University of Ghent, in Belgium, is doing this work. They've compiled a whole bunch of single cases, and are starting to mine the data these cases generate.

They have a website, in English, called the Single Case Archive, where you can sign up for free, and search for different parameters within papers that have already been published. It's still pretty primitive, but it's expanding.

At the meeting, the Ghent people started out talking about why they decided to do this work. They were concerned about the overestimation of the quality of measures. In particular, with convergent validity. They modeled this, and it turned out that, if there are three different outcome measures used for the same data, the convergent validity is extremely poor (correlation coefficient 0.0-0.45).

They also modeled the impact of the measurement error, and it turns out to be abysmal.
Say you have a perfect measure, and you use it to measure 2 variables, x and y, and it turns out that x and y have a 0.60 correlation. If you then re-measure using a measure with a 0.45 correlation with the first, perfect measure, you will find that there is only a 0.12 correlation between x and y. So the true correlation between x and y is 0.60, but with a crappy measure, it looks like it's 0.12.
They figured this out with something called "Spearman's Disattenuation Formula".

One of the speakers showed a graph of a treatment, where interpersonal factors were being measured. There was an unequivocal improvement in the patient's ratings over the course of the treatment. However, this happened to be the speaker's patient, and he knew that the treatment was a disaster, and that the reason her interpersonal measures improved was that she was completely isolating herself.

So context is key, and you don't get that kind of data from a checklist. You get it from a detailed description. I can't wait to see where this research goes.


Well, that's my take on this year's meeting. Signing off.

First Day at The Waldorf

I know it's Saturday, but the meeting is quite a whirlwind, so I'm gonna start back on Wednesday and work chronologically. My Wednesday groups were:

1. On Being Supervised: The Science and Art of Teaching in a Supervisory Relationship
2. Workshop on Psychotherapy Training: Who Are We Training and How Do They Best Learn?
3. The Analyst's Experience of Loss and Death
4. Lacanian Approaches to Treatment of Psychoses

Note: I can't reveal any clinical material that was discussed, so I'm going to try to present a gist of what each group was like.

1. On Being Supervised...

This group was chaired by a friend of mine, which is the main reason I signed up for it, but it's good I did because it was excellent. The presenter was C. Edward Watkins, from Texas, who it turns out is not an analyst, but has written a lot about supervision. He talked about establishing a written contract with supervisees, indicating rights and responsibilities. When you consider how intimidating supervision can be, this is a great idea. He talked about the supervisory alliance, which is as essential as the therapeutic alliance. Plus the guy has the most wonderful Southern drawl.
One thing I would have liked to hear more about was parallel process, where the dynamic between the patient and the therapist starts to play out between the therapist and the supervisor. It can be eerie and a little embarrassing when it happens, but it helps to elucidate a lot that's going on in the transference.
What was really interesting though, was the discussion. Some people talked about the difficulty of teaching psychodynamic psychotherapy to pharmacologically minded residents. There's a lot of, "I dare you to convince me that this is useful when I can just prescribe meds or do CBT." Others said we, as supervisors, have to meet residents where they are and let our enthusiasm and knowledge spark their interest. Some complained that even residents who try to be interested often don't have an ability to appreciate or understand the impact of the unconscious. I said there needs to be a balance between encouraging enthusiasm and healthy skepticism. But the discussion shifted in the direction of, "Who pursues a career in psychiatry today, and what do they expect the nature of that career to be?" And, "Is it possible to be a psychiatrist without any sense of the workings of the unconscious?"

2. Psychotherapy Training.

I was really looking forward to this group, because I recently became (got suckered into being) the curriculum director of the psychodynamic psychotherapy training program at my analytic institute. The people presenting at this group have done a lot of work in the area of teaching psychotherapy, especially to residents.
I was disappointed, though. The presenters are co-authors of Psychodynamic Psychotherapy: A clinical manual, and Psychodynamic Formulation, which seem to be pretty popular, but which, in my opinion, advocate a cookbook approach. They talk about "operationalization", and use constructs such as, "Describe/Review/Link" and "Listen/Reflect/Intervene". And then they break these down into subsections. Their argument is that since residents are coming from a medical model that uses algorithms, they need to be given an algorithm. My argument would be that this is precisely why they need to NOT be given an algorithm.
The book I use, Becoming a Psychotherapist, by Rosemary Balsam, is wonderfully written and decidedly not cookbook. I wish I had known about it as a resident. It's a bit dated-there's a discussion of whether or not therapists should have ashtrays in their offices. But she manages to convey a sense of how to think about the patient, and what's going on in a given session, without resorting to lists of defenses and ego functions. The author, incidentally, was the first person to write about the analyst's pregnancy.

3. The Analyst's Experience of Loss and Death

This was the best group I attended. The presenter was a woman who talked about illnesses and deaths in her family, and how they affected her work with a particular patient. She included process material, so we could hear the give and take between her and her patient. The issues discussed included whether and how much information to disclose to a patient, and this can vary between patients. Some you tell more than others-you just have a sense of what's right. There are issues surrounding the analyst's wish to share, wish for connection, and the need to say aloud and make real what is so pressing internally.
There was a discussion about the holding environment that we create for our patients, and wondering what creates the holding environment for us, that allows us to do our work.
One of the main questions was, "Does the patient ever really not know?" given that there are always unconscious communications taking place.
Then there was the discussion of what happens after. How does the analyst work with the patient's fantasies about what's happened? These days, lots of information is available to patients online, and they do learn about us, even about our tragedies. And some patients treasure the idea that they know something about the analyst, that the analyst doesn't know they know, and will not discuss their thoughts and feelings.
The presentation was incredibly moving, so much so, that many of the people in the room felt comfortable enough to talk about their own losses, and how these have affected their work. My feeling is that a presenter who can describe such painful experiences, and create an environment that allows people to open up about their own pain, has done something right.

4. Lacanian Approaches to Treatment of Psychoses

I signed up for this group because I have a psychotic patient with whom I feel I'm hitting a dead end in therapy, and I wanted a new perspective. I trained in a Freudian, ego psychological model, so I know nothing about Lacan, except that he seems to be very popular among some analytic sectors, and that Lacanian work advocates intentional lack of clarity, to open up avenues of interpretation for the patient.

Since this group was highly case-based, I can't write about what was discussed. I thought, instead, that I'd try to write about some of the Lacanian concepts that came up in the discussion.

This is from Wiki:

Jacques Marie Émile Lacan (13 April 1901 – 9 September 1981) was a French psychoanalyst and psychiatrist who has been called "the most controversial psycho-analyst since Freud". Giving yearly seminars in Paris from 1953 to 1981, Lacan influenced many leading French intellectuals in the 1960s and the 1970s, especially those associated with poststructuralism.

Lacan's first official contribution to psychoanalysis was the mirror stage, which...describes the formation of the Ego via the process of objectification, the Ego being the result of a conflict between one's perceived visual appearance and one's emotional experience. This identification is what Lacan called alienation.

The Three Orders

The Imaginary is the field of images and imagination, and deception. 

The Symbolic order structures the visual field of the Imaginary, which means that it involves a linguistic dimension... Language has Symbolic and Imaginary connotations...

The Real, for Lacan, is not synonymous with reality. Not only opposed to the Imaginary, the Real is also exterior to the Symbolic. Unlike the latter, which is constituted in terms of oppositions (i.e. presence/absence), "there is no absence in the Real." Whereas the Symbolic opposition "presence/absence" implies the possibility that something may be missing from the Symbolic, "the Real is always in its place."

The big Other is designated A (for French Autre) and the little other is designated a. 

"1. The little other is the other who is not really other, but a reflection and projection of the Ego. He [autre] is simultaneously the counterpart and the specular image. The little other is thus entirely inscribed in the imaginary order.

2. The big Other designates radical alterity, an other-ness which transcends the illusory otherness of the imaginary because it cannot be assimilated through identification. Lacan equates this radical alterity with language and the law, and hence the big Other is inscribed in the order of the symbolic... The Other is thus both another subject, in his radical alterity and unassimilable uniqueness, and also the symbolic order which mediates the relationship with that other subject."

The Name-of-the-Father (French Nom du père) is a concept that Jacques Lacan developed from his seminar The Psychoses (1955–1956) to cover the role of the father in the Symbolic Order.

I don't understand any of this, but I think the idea, at least with respect to psychoses, is for the patient to get unstuck from the Imaginary order, and make his way at least to the Symbolic order, if not to the Real. Or it's The Emperor's New Clothes. I can't tell.

That's it for today. Next up: Winnicott in Aspergers; Self-Disclosure; and Single Case Report Research.

Tales from the Waldorf

This week is the annual winter meeting of the American Psychoanalytic Association (APSaA), which always takes place at The Waldorf in NYC. I'll be attending a number of the sessions, and I'll report back on what I learn.

The first time I attended the meeting, I was a PGY-3, because my supervisor, a truly hard-core analyst, encouraged me to go. I was a bit skeptical, so instead of putting in for conference time, which I probably wouldn't have gotten anyway, I scheduled my call so I would be post-call on the first full day of the meeting (I could leave the hospital by 11, and I was off the rest of the day). Of course, I hadn't slept at all, and by the time I got there, I was psychotically tired. I'd never been to The Waldorf before, and I had no idea where I was going, but I spotted a man wearing a tweed jacket and a cashmere vest, and I figured he must be an analyst, so I followed him.
Worked like a charm.
In retrospect, I'd have to say that attending the meeting that first time was a nodal point in my decision to pursue analytic training. It was a bit intimidating-try sitting in a room with 50 analysts talking about masturbatory fantasies (not their own)- but people were warm and encouraging. They had a very reduced fee for residents, something like $25-, and they had special sessions intended just for residents and students.
The important part, though, was the experience of listening to case presentations. I was a PGY-3 then, so I'd written and listened to my share of intakes and H&P's. I had never heard a case presented in this way. I had never walked away from a case conference in residency or medical school with such a full, deep understanding of who the patient was-what his early life was like, how it influenced his way of being in the world, how he relatedness  to others, what his wishes and fears were, his sense of values, his conflicts, fantasies, imagination, sexuality, anxieties.
Amazing.
And even better were the questions people asked. The first group I attended was about Psychoanalysis and Technology. I went in thinking (granted, I hadn't slept) it would be about what technologies were useful, what new and cool gadgets were on the horizon. No. It was more like, How does one handle silence in a phone session? Has the patient put the phone down? Did the call get cut off? Is there more tension because there's nothing to look at? In a long distance analysis, where does one position the video camera? Should it be pointed at the analyst, or the ceiling above the couch? Where does the patient place her camera? What is the meaning of the camera to the patient? Does it become an object that represents attachment to the analyst, the way medication can? Does it contribute to voyeuristic fantasies?
Again, different from and so much more than I was accustomed to.

There are hundreds of discussion groups, workshops, symposia, etc. There are sometimes fun talks on Saturday afternoons. One year they had Lorraine Bracco talking about her role as the psychiatrist on The Sopranos. They had Andrew Jarecki showing extra clips from Capturing the Friedmans. They had Daniel Menaker speaking about his book, The Treatment, a novel about a man in analysis, and at the same talk, Oren Radovsky, who directed the movie based on the book.

Here's a smattering of some of the groups:

*The Analysis of Masturbatory Fantasies: Theory and Technique (I believe that's technique of analysis)
*The Integration of Psychoanalysis and Couples Therapy
*Schizoid Modes in Narcissistic and Borderline States
*Freud as a Letter Writer
*Pharmacotherapy and Psychoanalysis
*Conversations for Analysts: the Embodied Experience of Analytic Listening
*The Analyst's Pregnancy
*Effects of the Holocaust on Survivors and Family Members
*Emerging Perspectives on Gender and Sexuality: Online Relations
*Psychoanalysis of Twins
*Edward Albee's "Who's Afraid of Virginia Woolf?" Are You?
*Love, Sex, and the American Psyche: Political Sexual Scandal
*Psychoanalytic Aspects of Assisted Reproductive Technology
*Trauma and Mastery Through Art: The Life and Work of Frida Kahlo
*Research on the Relation of Psychoanalysis and Neuroscience
*"Facing Death" Psychoanalysis and Psychoanalytic Psychotherapy of Patients with Cancer
*Privacy: A Quaint and Anachronistic Concept? (for residents, trainees, and students)
*Happy Endings in Real Life and in the Cinema

I'll get to the details of the groups I've attended in the next post. So far, four, on supervision, psychotherapy training, psychosis, and loss/death.

Til Then...

A New Low

Just when you thought it was safe to have health insurance... I mean, there's the Affordable Care Act, that at least makes it impossible for insurance companies not to insure you if you have a pre-existing condition, even if there are tons of problems with the Act. And there's the Mental Health Parity thing. You'd think that would provide some protection.

Skeptical by nature, I assumed insurance companies would come up with new and interesting ways to bite. And they have not disappointed.

A patient of mine submitted a claim a while back. A couple months later, when it wasn't reimbursed, the patient followed up, and sure enough, the insurance company had no record of the claim. (I happen to know that the claim was submitted properly). The patient re-submitted the claim, and the insurance company's response was that it was submitted too late, so they wouldn't reimburse. (I think there's a similar joke about a dry cleaner).

The patient appealed. Forms were filled out. Phone calls were made. More forms were filled out.
And now, another form needs to be filled out to "justify" out-of-network services, even though the appeal is about the supposedly late submission of the claim. My job, in this, is to cite two examples in "the literature" explaining why the patient requires out-of-network services.

When I learned this, my first thought was, "How am I supposed to come up with that?" But after some thought, I decided there are a couple arguments to be made, characterized by certain lines of inquiry.

1. Continuity of Care-do patients fare better when they don't switch providers?
2. Therapeutic Alliance-related to continuity of care, but also different, since it is possible to continue care with someone with whom you have a poor therapeutic alliance.

And there's an uncomfortable "3", which is, "Do patients actually have better outcomes with out-of-network providers, and if so, why?"  Related to this is, "Are there discernible differences between providers who accept insurance, and those who don't?"

So I thought I'd make lemonade and post about researching these ideas. I'd prefer sparkling limeade with coconut, but we're talking insurance companies here.

I searched, "continuity of care psychiatry", and got a bunch of links. And then I got more links from those links. Some of the articles were about defining the meaning of continuity of care. Others seemed to just assume that continuity of care was a good thing.
There was a reference to the National Service Framework for Mental Health, which is a 2001 Department of Health document from the UK, too long for me to read in full, but the source I got it from (can't remember) claimed that it recommends continuity of care as essential.

Here's more:

Intensity and Continuity of Services and Functional Outcomes in the Rehabilitation of Persons with Schizophrenia

Clients who...had fewer gaps in service delivery achieved greater rehabilitative improvement in social, work, and independent living domains and had fewer days of hospitalization.

Another article that seems critical is:

Tessler RC. Continuity of care and client outcome. Psychosocial Rehabilitation Journal 1987; 11(1):39-53.

Unfortunately, I couldn't track it down online. Not even the abstract.

There's what looks to be a not-quite-on-my-target paper, Continuity of care in mental health: understanding and measuring a complex phenomenon, but the bibliography is promising.


I found this article in the "continuity of care" search:

Therapeutic Alliance and Psychiatric Severity as Predictors of Completion of Treatment for Opioid Dependence

among patients with moderate to severe psychiatric problems, less than 25 percent with weak therapeutic alliances completed treatment, while more than 75 percent with strong therapeutic alliances completed treatment...In this patient subgroup, a strong therapeutic alliance may be an essential condition for successful treatment.


Next I searched, "therapeutic alliance and treatment outcome."

I found this article in JAMA Psychiatry:

The Role of the Therapeutic Alliance in the Treatment of Schizophrenia
Relationship to Course and Outcome

This study examined the relationship of the therapeutic alliance to the treatment course and outcome of 143 patients with nonchronic schizophrenia... Results showed that patients who formed good alliances with their therapists within the first 6 months of treatment were significantly more likely to remain in psychotherapy, comply with their prescribed medication regimens, and achieve better outcomes after 2 years, with less medication, than patients who did not.

And this one from J consult Clin Psychol:

The relationship between the therapeutic alliance and treatment outcome in two distinct psychotherapies for chronic depression.

This study tested whether the quality of the patient-rated working alliance, measured early in treatment, predicted subsequent symptom reduction in chronically depressed patients...A more positive early working alliance was associated with lower subsequent symptom ratings in both the CBASP (cognitive behavioral analysis system of psychotherapy) and BSP (brief supportive psychotherapy),...p < .001.

Then there's the psychoanalytic literature. There are a ridiculously large number of hits for "therapeutic alliance" and "analytic dyad", but they're mostly about the meaning and development of those elements. It's axiomatic that a good alliance is a necessary part of any treatment.

I also searched "discontinuity in psychiatric care", and mostly I got measurements-e.g. how many new patients in a clinic drop out of treatment. They didn't seem to address the problem of what happens to patients when they stop treatment, or switch treatment providers.

I searched:
"patient outcomes in psychiatric clinics with frequent change in providers"
"Do psychiatric patients get worse when they switch providers"
"Do psychiatric patients drop out of treatment when they switch providers"

Nothing came up that seemed to address what typically happens in an outpatient clinic, where there's resident turnover every year, and what that does to patients, which is what I was hoping to find with those searches.

Now on to point "3", patient outcomes with out of network vs. in network psychiatrists. That search came up with things like, "benefits of antidepressants" and "Providers are responsible for the correct submission of claims", under OUTreach...Network.

One thing we do know is that fewer psychiatrists than doctors of other stripes accept private insurance:

The percentage of psychiatrists who accepted private noncapitated insurance in 2009-2010 was significantly lower than the percentage of physicians in other specialties (55.3% ...vs 88.7% ... P < .001) and had declined by 17.0% since 2005-2006.

But what are the differences between shrinks who decide to join an insurance network, and those who don't? And whose patients do better? I wonder if the study's been done. And if it hasn't, someone should do it, because the results are not simply academic.

Practice Fuse-Up?

There was an anonymous comment on my post, E-Rx Update and Review (thanks, BTW), that linked to a concerning article in Forbes about Practice Fusion.

For those who haven't been following, Practice Fusion is a free electronic medical record system. I signed up for it because it allows me to e-prescribe, which I and every other doctor in the country will be required to do starting in March of 2015,and I don't want a last minute scramble-the I-STOP deadline had to be postponed because many prescribers didn't have an HCS account, although I'm not sure how they were getting their rx pads before that. I don't use Practice Fusion for patient records, mainly because the data is stored in the cloud and it's not clear who owns it.

However, the Forbes article is not about storage of patient data, or even security of patient data. At least, not through the health record maintained by the doctor. According to the article, Practice Fusion has set up a Yelp-like site, Patient Fusion, where patients can have access to their health records, if they agree to this with their doctors. They can also schedule appointments, and read and write reviews about doctors. The writing reviews is where the problem came in.

Apparently, patients were writing reviews and including personal information about themselves, sometimes very intimate information (the article calls them, "Burning Sensation [Down There]' Reviews"). And these patients were not aware that their comments, and sometimes names, would be posted publicly.

This is a screenshot of what I could find of the review page:

It's not clear to me if this is the same form that these patients filled out, or if it's been revised since the company realized personal information was being presented publicly. The fine print under "please leave a review for your provider" reads: for your protection, do not include any personal information.

And the fine print under "Patient Authorization" reads:

I authorize my provider and Practice Fusion, Inc. to publish my review on the Practice Fusion website, together with my first name (subject to my unchecking of the "Keep this Review Anonymous" box above). The purpose of publishing my review is to make it available to patients and prospective patients of my provider, and other members of the public. I understand that my provider and Practice fusion will not publish any personal information about me, except my first name (subject to my unchecking of the "Keep this Review...

That's where the screenshot ends. I tried to find myself as a provider so I could set up a Patient Fusion account and get more information, but I wasn't listed. I guess I have to fill out or set up something special to be listed as a doctor.

Here's the thing. Practice Fusion clearly needs to take some responsibility in this. There should be a popup window with a reminder: Please be sure not to include personal information. Or something like that.

But in the age of Facebook, and the era of complete absence of privacy that it ushered in, don't the people who wrote the reviews need to have some responsibility? Everything was filled out online, so you can't say they're not tech-savvy at all.  Do people really not know what it means to write a review? Don't people buy stuff from Amazon?

I don't mean to "blame the victim" here. And the Forbes article was waving around some sensationalism to get read. But I'm very uncomfortable with the whole paternalistic approach, like where government tries to dictate how much soda a person can drink, or how much salt a chef can cook with (this was proposed but thank goodness shot down several years ago).

Maybe the whole idea is that people want to believe a greater power or authority figure is taking care of them and making decisions for them, so they don't need to think and feel responsible, and so they can feel protected. And maybe the price of this protection is privacy. If you want mommy and daddy to make sure you're safe, then they have to know everything you're up to.

Is that a good thing?

A Quick 329

I don't know why I decided to do this today. Maybe because I'm finally finished writing my Carlat article, and I also finished some other writing I needed to do. Or maybe it had to do with reading Ben Goldacre's most recent post on Bad Science, Public Accounts Committee issues damning report on clinical trial results being withheld. But I decided to look up the actual Paxil Study 329.

I mean, the infamous Paxil Study 329, the one that got GSK fined 3.3 billion dollars.

Quick review. It's paxil in adolescents, ages 12 to almost 19, in the acute phase, at least 8 weeks, of a unipolar major depressive episode, as defined by DSM III-R, with a HAM-D score >12. The study took place between April 20, 1994 and May 7, 1997 (for the acute phase), and February 15, 1998 (for the continuation phase). Subjects were randomized to paxil 20-40mg, imipramine 50-300mg, and placebo. Primary outcome measures were change from baseline on the HAM-D total score, and proportion of responders with a 50% reduction in the total HAM-D or a score of < 8. There were also secondary measures, and adverse events were evaluated and followed.

The result:

The analyses of these measures support that paroxetine is beneficial in treating
adolescents with major depression, but the support is derived mainly from the
secondary measures. In the protocol defined primary endpoints, the placebo
response was large and the magnitude of the benefit of paroxetine response over placebo was modest and did not achieve statistical significance (boldface mine).

And the adverse events?

Adverse Experiences:
The nature and incidence of adverse events reported for the paroxetine group were
similar to that reported for adult depressed patients receiving paroxetine in
controlled trials of comparable duration[1] and as described in the Paxil U.S.
prescribing information. Two exceptions to the profile seen in adults include tooth disorder and hostility. The latter term includes aggressiveness and conduct disorders. These exceptions may be related to the age of the study population. As
in the adult, adverse events were more likely to occur during the initial weeks of
treatment. Analysis by age suggests that events associated with the nervous
system (dizziness, sleep problems, and conduct disorders) were more likely to
occur in the younger subset (<15 yrs.).
There were no deaths during the trial. Serious adverse events occurred in 18
patients, 11 in the paroxetine group, 5 in the imipramine group, and 2 in the
placebo group. One of the paroxetine patients experienced migraine headache
during down titration after completing 8 weeks of treatment. For the remaining
patients the events were psychiatric in nature and included worsening depression,
suicidal ideation/gestures, and conduct disturbances (hostility). In the imipramine
group, one patient developed a maculopapular rash, one had dyspnea associated
with chest pain, one reported auditory hallucinations, and two were reported to
have serious conduct disturbances (hostility). In the placebo group, the two
serious events were worsening depression. (boldface mine)

The wording is a little funny. My reading is that 11 paxil subjects had adverse events. One of these had migraines. the other 10 had worsening depression, suicidal ideation/gestures, and/or "hostility". There were a total of 93 paxil subjects, so roughly 11% of these became more depressed, suicidal, and/or hostile. That's vs. 2/95 (2%) of imipramine subjects, and 2/87 (2%) of placebo subjects. And since none of the placebo subjects experienced either hostility or suicidality, it kinda looks like those might be related to the active meds.

Immediately following the paragraph above, there's this table:

Notice that the description in the table, "emotional lability", does not match that in the prose, "worsening depression and suicidal ideation/gestures".


And where did I get this information?

BRL-029060/RSD-100TW9/1/CPMS-329  Report Synopsis, from gsk.com.

I wasn't able to track down the actual study. I'm guessing what I did find came out during legal proceedings.

But the bottom line is, in the adolescents studied, paxil showed no benefit over placebo, and caused suicidality, worsening depression, and hostility in a hefty percentage.

How did this get past the powers that be, and what DON'T we know about other meds?