Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Thursday, February 20, 2014

Why Does this Bother Me?

I got an email today about the annual meeting of the APA, which is in NYC this year. I suppose I could attend, even though I terminated my membership in the APA a while ago. This was in the email:

APA 2014: Changing the Practice and Perception of Psychiatry

APA President Jeffrey Lieberman, M.D., is using the Psychiatric News Alert as a forum to reach APA members and other readers. This column was written by Dr. Lieberman and Philip Muskin, M.D., chair of the APA Scientific Program Committee. Please send your comments to pnupdate@psych.org.

Annually, thousands of mental health professionals descend on a major American city to participate in a three-ring circus of pedagogic activities that comprise the annual meeting of the American Psychiatric Association. This event is an academic smorgasbord of all information relevant to psychiatric medicine and mental health care. It provides one-stop shopping for clinicians who wish to avail themselves of the latest scientific developments and all the education needed to practice their craft. The annual meeting is the highlight of the year for U.S. psychiatry.

APA’s 167th Annual Meeting will take place May 3 to 7 in New York City and will be the epicenter for those who wish to learn of emerging knowledge and connect to leaders in the field of psychiatry. New York is a perfect place to host this year’s meeting, given the extraordinary and historic events of the past year, including the launch of DSM-5, the release of the final rule for the Mental Health Parity and Addiction Equity Act, further implementation of the Affordable Care Act, and the emotionally wrenching discussion of mental illness and violence in the media.

The theme of the 2014 annual meeting is aptly titled “Changing the Practice and Perception of Psychiatry,” reflecting the historic transformation in how our profession will be practiced, as well as perceived by our medical colleagues and the public at large. The Scientific Program Committee, chaired by Phil Muskin with Co-Chair Cam Carter, has produced an amazing program with a who’s who of luminaries scheduled to speak. The Opening Session will feature a “Dialogue on Science and the Media” that I will moderate between Nobel Laureate Eric Kandel and the acclaimed actor Alan Alda. The Convocation Lecture will be delivered by a major political figure who is leading major legislative initiatives in mental illness. Look for more information in a future issue. 

I happen to be a huge Alan Alda fan, and that alone is a draw. But my skin is just crawling, and I'm not sure why. 

Here's a link to the full text of above. Many of the sessions are organized into tracks, such as forensics, child/adolescent, ethics. There's a mentoring track for residents. and a track dedicated to military health care.

There's also an integrated care track:

The Integrated Care Track features interactive sessions applicable to every psychiatric physician in this current culture of health care reform and comprehensive patient-centered service. By participating in workshops led by experts like Lori Raney, M.D., you will learn practical skills to prepare for leadership roles of the psychiatrist within a collaborative care team. The CPT coding workshop, chaired by Ronald Burd, M.D., is another educational opportunity relevant to all due to changes in health care financing and reimbursement that occurred at the start of 2014.

"Leadership roles of the psychiatrist within a collaborative care team." This is a definite formicatory sentence. I wanna reply, "You mean, as opposed to psychiatric roles of the psychiatrist within a collaborative care team," because in a collaborative care model, the psychiatrist doesn't see patients, just supervises those who do, and signs off on the charts of these unexamined patients. And as Socrates said, "The unexamined patient is not worth treating." Or something like that. (I was gonna write, "not worth living", but that sounded way harsh.)

I think what bothers me about the meeting is everything that's left unsaid. There's all this, "Yay! DSM-5! Here's how to use it!" Rather than, "DSM-5, let's talk about the controversy". 

And there's, "Yay! RDoc! NIMH!!" as though we're already at an advanced stage of knowing how the brain produces psychiatric illness. 

"Yay! Psychopharm!" as though there are no questions about efficacy and safety, even with Paxil study 329 glaring in everyone's face. 

I also hate the phrase, "Patient Centered Care". 

As opposed to what? Kumquat-Centered Care?

And I'm irritated by the notion that the APA meeting presents, "all information relevant to psychiatric medicine and mental health care." Do they really think there's no valid perspective on psychiatry outside that of the APA?

I glanced at the program, and I was pleased to find a reasonable emphasis on psychotherapy, especially of the psychodynamic variety, and Kernberg and Fonagy will be there. And Kandel is always a welcome presence.

I'm not sure why I find the whole thing so icky, or why I expect anything to be different. I just remember being at the meeting in NYC 10 years ago, and the most impressive thing was all the pharmaceutical presentation areas. Maybe there won't be as many this year. And maybe they're trying to keep them out of the program. 

I found this paragraph on page 7:

Sunshine Act
Some of APA’s non-CME accredited events and some refreshments at APA events are sponsored by pharmaceutical or medical device companies. Participation in these events/ food offerings may be reportable under the Physician Payment in the Sunshine Act.

Just this one little blurb. Like, hey, that's not a herd of elephants we all see traipsing about the Javits Center.

I feel like there's some big issue being sidestepped. That the influence of industry is so integral that no one even bothers to talk about the conflicts of interest. I know there's a lot of excess hype about David Kupfer's ownership of Psychiatric Assessments, Inc., which provides assessment instruments to be used in conjunction with DSM-5 (Link), but it's as if the meeting just goes along its merry way, completely oblivious to Voldemort's shriveled, twisted soul lying under a bench.

As though psychiatry isn't a mess. 

It really bothers me.


  1. Richard Kogan usually plays piano and talks about the life of a composer. Go to that. He's really amazing and the composers all lived before pharmaceuticals. I'm going to hear Andrew Solomon, author of Far From the Tree speak. And I hear there is a shrink rapper talking at a work shop on on-line reputations. That would be me. It's fun to catch up with friends. I won't tell anyone if you don't go to the Exhibit Hall.

  2. I do not know any of you personally but I know of your blogs. Is anyone interested in putting together a workshop for 2015 on psychiatrist bloggers? You can find me at http://www.madinamerica.com/author/ssteingard/
    Maybe we could get Mickey Nardo to come. I think it would be interesting to share our experiences in doing this, what drives us to do this, etc. Dinah - you do not know me but one of your shrink rap colleagues was a teacher of mine many years ago.

  3. I tried to comment but it did not show up. Perhaps it is waiting for review. If so, feel free to delete. I appreciate this blog. I went to the IPS meeting in October hoping to find some like-minded colleagues and I had the same "ick" feeling. It just seemed that we were proceeding with business as usual despite such serious questions about our profession.
    I was also writing to see if there would be an interest in having a workshop or symposium in 2015 on Psychiatrist bloggers. There are many of us, representing somewhat different views. It could be interesting.

  4. The APA is psychiatry's lobbying organization. If psychiatrists feel oppressed by government regulation, it's because of APA negotiations for psychiatry -- or because the APA failed to be present at the table. In prior years, much of APA's lobbying budget was contributed by pharmaceutical companies with efforts directed towards support drug approval and prescription.

    Fueled by pharma money, the APA was an ally in promulgating the belief that psychiatric drugs -- and therefore, psychiatric treatment and diagnosis -- could be prescribed safely (with only very rare side effects), conveniently, and cheaply by non-psychiatrists. The APA certainly has not stood against this assumption, and continues to avoid the issue.

    Its enthusiastic alliance with pharma having undermined the purpose of psychiatry (as David Healy pointed out, the APA's 2012 "we believe that antidepressants save lives" obviates the role of psychiatrists), the APA is putting the best face on its abdication of responsibility to the profession.

    If psychiatrists want to influence government regulation, the APA is the logical conduit. The direction of the APA should be of great concern to clinicians. A very small number of people decide the results of APA elections. http://www.psych.org/network/board-of-trustees/apa-national-elections has a link to 2013 results. Looks like only about 5,000 members voted. Paul Summergrad, M.D. is the new president-elect with 3,304 (62.1%) of the vote.

  5. By the way, Andrew Solomon did not suffer from debilitating depression, the basis of his book The Noonday Demon, often cited as a demonstration of antidepressant necessity and efficacy. What he was suffering from was adverse reactions to psychiatric drugs.

    First, he had paradoxical or rebound reactions to sleeping pills he took after being hospitalized for kidney stones.

    His adverse drug reaction was misdiagnosed by Dr. Alfred Wiener, a psychopharmacologist, who put him on a series of antidepressants plus benzodiazepines.

    After some months, Solomon cold-turkeyed off his drug cocktail and suffered severe withdrawal symptoms, which were diagnosed as "agitated depression." He went back on a series of antidepressants plus a hefty dose of Xanax, which he described as a "lifesaver."

    Yes, indeed, Xanax would be a lifesaver if you were suffering from severe Xanax withdrawal.

    This is all detailed in a January 12, 1998 New Yorker article, Anatomy of Melancholy http://www.ucdenver.edu/life/services/counseling-center/Documents/Anatomy-of-melancholy.pdf At the end of the article, Solomon is looking forward to a lifetime on psychiatric drugs -- despite their continuing adverse effects.

    If one is familiar with adverse reactions to psychiatric drugs, Solomon's psychiatric history is readily recognized as iatrogenic, not of serious depressive illness.

  6. My feelings about the APA and its annual conference match your post very well. I've never been a member and only attend the conference when it's in San Francisco, about every ten years. It was in SF last year. The pharma flavor seemed somewhat toned down from ten years prior, but there's still plenty. There are some sessions devoted to "controversies," as well as inspiring talks by Kernberg and the like if you seek them out. And it's certainly an opportunity, as Dinah says, to catch up with friends. The conference is so big that there's truly something for every psychiatrist — and by the same token, there are so many concurrent sessions that presenters end up preaching to the choir, especially if their topic is non-traditional in any way. The end result, for me, was a kind of stranger-in-a-strange-land feeling. All in all, I find the whole thing icky too, and felt some relief after last year's that I wouldn't be tempted to go again for about another ten years.

    Altostrata's point about the APA election is a good one. It wouldn't take a huge number of like-minded "alternative psychiatrists" to (join and) vote as a bloc, to change the leadership of the APA. The main hurdle is the "like-minded" part. Critics of mainstream psychiatry run the gamut from those who merely seek more transparency and less conflict of interest, to those who feel psych meds do more harm than good; from those who champion psychodynamics, to those who espouse manualized psychotherapies; from naturopathy to spiritual crisis to the myth of mental illness, and so on. A coherent alternative platform seems a prerequisite to changing the APA, and even then it's just a start. I hope I don't shock anyone by suggesting that the direction of the APA is set more by the monied stakeholders than by the 3300 members who voted for the new president.

    1. I kinda doubt that last is a shocker.
      I'm actually thinking of going because of Dinah's comment. If she's there, it can't be all bad. And I really am an Alan Alda fan. His mom suffered from schizophrenia-he's written about it-so I assume that's part of the reason he'll be there.