Uh, Houston, we got a problem here...

[JMC_MarineCorps]

---

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Docs: Antipsychotics often prescribed for 'problems of living'

http://vitals.msnbc.msn.com/_news/2...otics-often-prescribed-for-problems-of-living

What are we doing? Seriously...


See also:

Are Antipsychotics Overprescribed?

http://www.medscape.com/viewarticle/737587

 

[nitemagi]

Indeed. It's crap prescribing.

 

[Suedehead]

love ghaemi

 

[peppy]

I've always held the view that part of being a good psychiatrist is having the judgement to know when it's NOT appropriate to write a prescription.

 

[splik]

in my experience primary care docs are the worst offenders - they are prescribing seroquel for everything. the drug companies are partly to blame -it has not escaped astra zeneca's notice that seroquel is a useless antipsychotic so they have been encouraging PCPs to use it for anxiety or as a sleeper! i have a friend who was prescribed zyprexa for anxiety and insomnia! she was horrified when i told her it was an antipsychotic meant for treating schizophrenia and bipolar disorder!

considering how toxic these drugs are, not just in terms of metabolic syndrome, but also in terms of brain shrinkage (the long-supressed evidence that antipsychotics shrink cerebral volume by up to 10% has finally come out), movement disorders, and cognitive impairment, they should not be prescribed for just anything.

 

[JMC_MarineCorps]

Sadly, this is not by any stretch of the imagination limited to PCPs.

This "diagnosis creep" is pervasive among our own and what really is "anxiety" gets coded as "bipolar" (this is rampant where I live where resources are severely restricted to the most ill, ie SMI "serious mental illness") and what better medication is there for "bipolar" (emphasis added) than the "drugs du jour" of our time.

The social, legal and clinical implications are worrisome.

We seriously have a problem within our profession. The PCPs have an excuse.

 

[nitemagi]

Sadly, this is not by any stretch of the imagination limited to PCPs.

This "diagnosis creep" is pervasive among our own and what really is "anxiety" gets coded as "bipolar" (this is rampant where I live where resources are severely restricted to the most ill, ie SMI "serious mental illness") and what better medication is there for "bipolar" (emphasis added) than the "drugs du jour" of our time.

The social, legal and clinical implications are worrisome.

We seriously have a problem within our profession. The PCPs have an excuse.

The creep follows from symptom-based prescribing without paying attention to the individual as a whole or the context to the symptom. Not every "voice" is psychosis, nor is every "anxiety" requiring meds.

 

[JMC_MarineCorps]

The creep follows from symptom-based prescribing without paying attention to the individual as a whole or the context to the symptom. Not every "voice" is psychosis, nor is every "anxiety" requiring meds.

Right you are sir, but again, this is where we find ourselves.

Somebody asked in another forum about the prescribing rights of psychologists and the state of our profession. I dare say that if this is where we are headed, ie any mention of one of these "voices," "mood swings," "racing thoughts" or "can't sleep" = antipsychotic. Why couldn't any provider (PhD, PsyD, PA, NP) do this?

I agree, knowing when not to prescribe is key, but I argue (and I'm certainly not alone) that we allow social and political forces to sway our judgment and clinical decision making.

The sky isn't falling, but we do have a problem.

Curr Psychiatry Rep. 2010 Dec;12(6):479-89.
The bipolar spectrum: myth or reality?
Youngstrom E, Van Meter A, Algorta GP.

 

[Ibid]

but I argue (and I'm certainly not alone) that we allow social and political forces to sway our judgment and clinical decision making.

The sky isn't falling, but we do have a problem..

The last time psychiatrists allowed social and political forces to sway judgement they totally forgot about the people infront of them and the results.....well you know what the results were. http://en.wikipedia.org/wiki/Action_T4

When patients last line of defense forgets the patient the sky might as well be falling imo.

 

[OldPsychDoc]

I think we need to take different approach here.

First off, does the use of the phrase "problems of living" raise ANY hackles here?
(Hint: http://en.wikipedia.org/wiki/Thomas_Szasz)

I think that this article was sensationalism, pure and simple. Whip up the most extreme examples as characterizing the entire profession, and close with the challenge: "In the short term, I don't see a change in this trend unless external forces intervene." (Emphasis mine.)

Nope folks, let's start with some INTERNAL forces of intervention--educating ourselves, our trainees, and our patients about what we do and do not know about psychiatric symptoms. As has been pointed out previously, we really don't know yet what "schizophrenia" or "major depression" is in terms of pathophysiology, let alone how the meds work if they have been "FDA approved" to treat these categorically-defined conditions. We do need to appropriately treat symptoms outside of these categories with these medications. Our job, as always, is to communicate and document appropriate expectations for the use of these medications--not play into the hype of marketing, OR of dogmatically self-righteous non-prescribing. Our goal is to help patients--real people, who suffer real symptoms which may or may not fit neatly into artificial categories, or into the "all or nothing" portrayals of the media. And sometimes those "problems with living" do benefit from the judicious application of psychopharmacology.

 

[JMC_MarineCorps]

Nope folks, let's start with some INTERNAL forces of intervention--educating ourselves, our trainees, and our patients about what we do and do not know about psychiatric symptoms.

As always OPD, you are right on the money. I agree, the argument is in favor of raising the standard of care via internal forces, ie leadership, training, etc.

 

[whopper]

Incredibly idiotic psychotropic med prescribing is quite common even among psychaitrists. During my job as a court expert-witness where on average I saw about 8 people a week, at least one of them was on a med regimen so incredibly questionable it offended me because a patient was suffering.

Just a few examples, someone was manic and put on Neurontin---yes Neurontin to treat bipolar mania, a person with chronic kidney disease placed on lithium, a person without a seizure disorder placed on Keppra to treat seizures and the person became psychotic as a result of the Keppra, then the doctor put the patient on Lamictal to treat the psychosis and titrated it up to 200 mg within 4 days from nothing

I'd usually be asked by the judge or defense attorney on a patient that was involuntarily committed how long it would take for the patient to improve. In cases like this I'd usually say I couldn't give an opinion because the patient was not on the right treatment for their disorder.

In the last case with the patient put on Lamictal to treat Keppra-induced psychosis for a seizure disorder she never had, the family's face went through a mix of horror, anxiety and anger as I told the court that this treatment regimen was bogus, but guess what? According to the law, if the patient suffered from a disorder of thought (she did--psychosis though it was med-induced), and was a danger to others due to it (and she was), then the court is supposed to involuntarily commit the patient. The judge was so ticked off with the performance of that doctor after I explained what happened that she allowed discharge only on the condition that the family immediately bring the patient to the ER so she could be treated by another doctor, citing it fit the law's loophole of being able to discharge to a "lesser restrictive environment."

And I kinda...well just kinda said that this practice met the criteria of malpractice to give the family a little nudge. Maybe I shouldn't have done it but I was so offended as well.

 

[Suedehead]

Our field is in crisis. It's both deflating and invigorating.

I really like some (not all) of the solutions laid out in this article by Ronald Pies. With a title of "How American Psychiatry Can Save Itself" how can you resist?

http://www.psychiatrictimes.com/bipolar-disorder/content/article/10168/2040753

 

[JMC_MarineCorps]

From http://forums.studentdoctor.net/showthread.php?p=11986629#post11986629 on differential diagnosis:

To the OP--THANK YOU for noticing. As with all of my esteemed colleagues above, we see the label of Bipolar applied sloppily, often to justify provision of inappropriate care, or to mitigate stigma for the patient. (I might cynically suggest that pharmaceutical marketing and direct-to-consumer advertising has also played a part since the major second-generation antipsychotics have indications for bipolar disorder.) It is often easier to "medicalize" mood swings, emotional distress, and impulsivity than it is to educate about a chronic and difficult diagnosis. (Kind of like calling obesity a "glandular problem" instead of addressing it as a complex and chronic behavioral issue.)

So when that patient comes in complaining about "my bipolar" of which the main symptom is "I can love you one minute and want to kill you the next", it is definitely time to do some psychoeducation and start talking about DBT and stress management, not reviewing a list of medications and side effects.

You are making my argument for me, but you seem to take issue w/ somebody blasting the use of antipsychotics for "problems-of-living" and reference Szasz, while readily conceding that "it is often easier to "medicalize" mood swings, emotional distress, and impulsivity than it is to educate about a chronic and difficult diagnosis." Why is it easier?

Should we as individuals or as a profession be doing this? The answer, obviously, is no -- but we do or we attempt to steer clear of this behavior while watching others do it to the detriment of the patient and to our field.

I think we are all asking for a higher standard-of-care -- and we agree that intervention should come via INTERNAL sources.

 

[Ibid]

I think we need to take different approach here.

First off, does the use of the phrase "problems of living" raise ANY hackles here?
(Hint: http://en.wikipedia.org/wiki/Thomas_Szasz)

I think that this article was sensationalism, pure and simple. Whip up the most extreme examples as characterizing the entire profession, and close with the challenge: "In the short term, I don't see a change in this trend unless external forces intervene." (Emphasis mine.)

Nope folks, let's start with some INTERNAL forces of intervention--educating ourselves, our trainees, and our patients about what we do and do not know about psychiatric symptoms. As has been pointed out previously, we really don't know yet what "schizophrenia" or "major depression" is in terms of pathophysiology, let alone how the meds work if they have been "FDA approved" to treat these categorically-defined conditions. We do need to appropriately treat symptoms outside of these categories with these medications. Our job, as always, is to communicate and document appropriate expectations for the use of these medications--not play into the hype of marketing, OR of dogmatically self-righteous non-prescribing. Our goal is to help patients--real people, who suffer real symptoms which may or may not fit neatly into artificial categories, or into the "all or nothing" portrayals of the media. And sometimes those "problems with living" do benefit from the judicious application of psychopharmacology.

This isn't disagreement with what you subsequently wrote but with respect to Szasz did he not write "problems in living not of living".

As I understand it he included all of what is considered mental illness to be problems in living. While the article is about problems of living and positing occassional inappropriate doctor behaviour rather than the more general point Szasz was making.

Small point. Anyway I have to now go and raid my brushes for some more hairs to split.

 

[JMC_MarineCorps]

Our field is in crisis. It's both deflating and invigorating.

I really like some (not all) of the solutions laid out in this article by Ronald Pies. With a title of "How American Psychiatry Can Save Itself" how can you resist?

http://www.psychiatrictimes.com/bipolar-disorder/content/article/10168/2040753

That was a good article BTW, thank you.

I also appreciate your view http://forums.studentdoctor.net/showthread.php?p=11986629#post11986629

Cormorbidity is a tough subject for me. You mention comorbidity above. Are we a talking about a comorbidity between a personality disorder and a PRIMARY mood disorder? By 'primary,' I mean a dysfunction in the brain's natural ability to regulate mood, suggesting something is truly haywire, a disease? Or are we talking about a SECONDARY mood disorder that manifests similarly but suggests an external insult (drugs, life stressor, chronic abuse, etc, etc).

If you're talking about a secondary mood disorder then the 'comorbidity' is rather better explained by the external insults (and better addressed by addressing the external insults, ie therapy and maybe a med for support, etc.). I wonder if it's misleading to suggest there are two problems here...

 

[Ibid]

I think we are all asking for a higher standard-of-care -- and we agree that intervention should come via INTERNAL sources.

The trouble is every professional group says the same thing. Lawyers say leave the law to lawyers and worst of all most recently we hear bankers say leave banking to bankers, we know best. The sad fact is that all professions when left to their own devices tend to order things for their own benefit and needs, rather than the group they are intended to serve.

Just pointing out part of the challenge.

 

[digitlnoize]

You are making my argument for me, but you seem to take issue w/ somebody blasting the use of antipsychotics for "problems-of-living" and reference Szasz, while readily conceding that "it is often easier to "medicalize" mood swings, emotional distress, and impulsivity than it is to educate about a chronic and difficult diagnosis." Why is it easier?

Someone correct me if I'm wrong, but isn't it difficult to get reimbursement from insurance for a primary diagnosis of BPD? Hence the reimbursable axis 1 label of "bipolar" being used so the inpatient stay actually gets paid for.

And, what's a resident to do when pressured by the powers-that-be to do this?

FWIW, I've also met (in my limited experience) a number of schizophrenics/schizoaffectives who label themselves as bipolar, who definitely seem to meet the criteria for schizoaffective more than bipolar with psychotic features. I've encountered some hesitancy to label people schizophrenic...whether that's to make life easier for the patient or us, I'm not sure. Anyone else experienced any of this?

 

[whopper]

According to head of the mental health board in one of the counties I work in, for reimbursement one could actually get it for antisocial PD, and not borderline PD.

Ironic. If someone is literally a rapist with no regrets, he could get some type of government assistance for being such, but someone who has a potentially severe disorder that such as borderline PD that could impair their ability to lead a productive and happy because they were raped as a child cannot.

I don't know if it's something to do with this specific county or not.

As for borderline PD, hospitalization for most doesn't really help it out. The problem here is that it could take some time, often a few days to figure out if it was bipolar vs. borderline PD, and if you diagnose the latter, you might not get reimbursed.

The only type of borderline PD patient I can think of that benefits from hospitalization are the ones with a comorbid disorder where that disorder gets treated (e.g. borderline PD and bipolar DO) or if the borderline PD is severe (e.g. chronic suicidal ideation, severe suicide attempts), long-term hospitalization but only if that patient has a very good psychotherapist.

IMHO insurance companies ought to just reimburse period for any patient that meets a criteria of danger due to any psychiatric disorder for at least the first three days. Usually by the third day these things are sorted out. A problem that's happening is that several patients are getting misdiagnosed due to the bull$hit reimburse rules the insurance companies set up with several patients slapped with a bipolar disorder dx when they never had it to begin with. Then when they show up to the hospital again, and there's now a record of it, it only increases the odds that this vicious false cycle continues---with insurance companies paying for each hospitalization with a false diagnosis. You figure they would be wise to allow us to diagnose accurately and prevent this sort of thing.

Anyone else experienced any of this?

Several times.

 

[Suedehead]

That was a good article BTW, thank you.

I also appreciate your view http://forums.studentdoctor.net/showthread.php?p=11986629#post11986629

Hey, that makes my day. who doesn't like being quoted?

My residency training has turned into a long journey of looking for sanity in psychiatric practice. I've searched and searched for a sane way to think about and approach our patients. It's a mess. Bipolar versus borderline, brain versus mind, mechanisms of action versus med free trials versus placebo versus dependence.... blarg. I have a real hard time, for instance, trusting something as essential and basic as psychiatric epidemiology because I believe our models for diagnosis are so limited...

A few authors and a few mentors and a few patients have saved me from a nihilism, though. Nassir Ghaemi, Paul McHugh, David Brendel, Arthur Kleinman, Joanna Moncrieff, Peter Kramer, Jennifer Radden are some, though I have problems with many of the things they say. I've joined the (don't laugh) Association for the Advancement of Philosophy and Psychiatry... not because I fancy myself an erudite... I don't... but because these seem to be some of the few people who are addressing the mass confusion over what in the world it is that we are doing as psychiatrists. Incidently, the Association is having it's symposium in Philly to discuss the utility of the Biopsychosocial model - spoiler: Ghaemi's going to try to destroy it.

Even though I feel a need to "ring the bell" and "wake the town" and point out that the emperor is naked... I still love it. I'm not fighting psychiatry anymore. Instead i'm facing the vast complexity of what it means to be human. Will love it forever.

 

[atsai3]

Someone correct me if I'm wrong, but isn't it difficult to get reimbursement from insurance for a primary diagnosis of BPD? Hence the reimbursable axis 1 label of "bipolar" being used so the inpatient stay actually gets paid for.

And, what's a resident to do when pressured by the powers-that-be to do this?

FWIW, I've also met (in my limited experience) a number of schizophrenics/schizoaffectives who label themselves as bipolar, who definitely seem to meet the criteria for schizoaffective more than bipolar with psychotic features. I've encountered some hesitancy to label people schizophrenic...whether that's to make life easier for the patient or us, I'm not sure. Anyone else experienced any of this?

In my residency experience I would use the discharge summary as an opportunity to correct the record, i.e., this patient may have been diagnosed in the past with bipolar II but upon further information gained during this hospitalization it is clear the patient does not meet criteria and that the diagnosis is consistent with no Axis I disorder but rather a likely diagnosis of borderline etc etc etc. On several occasions the attending would meet with me later and suggest a revision. Most of the time I stood my ground with regards to the consistency of the documented record with the diagnosis, and the attending would concur. I never had an attending blatantly say "you need to revise the diagnosis or else there will be no reimbursement".

 

[JMC_MarineCorps]

"...Nassir Ghaemi, Paul McHugh, David Brendel, Arthur Kleinman, Joanna Moncrieff, Peter Kramer, Jennifer Radden are some, though I have problems with many of the things they say.

Paul McHugh, nice, the man has chutzpah! I used the former of the two below to help me summarize my thesis.

PTSD: a problematic diagnostic category.
McHugh PR, Treisman G.
J Anxiety Disord. 2007;21(2):211-22.

Problems with the post-traumatic stress disorder diagnosis and its future in DSM V.
Rosen GM, Spitzer RL, McHugh PR.
Br J Psychiatry. 2008 Jan;192(1):3-4.

Even though I feel a need to "ring the bell" and "wake the town" and point out that the emperor is naked... I still love it. I'm not fighting psychiatry anymore.

I tend to think we all love it, that's why we choose to speak out here, in the hopes of finding like-minded individuals who have no desire to leave the profession but instead wish to strengthen it. It's not a "love it or leave it" thing like my friends in the South would say.

We see the problems we face in this field (on a daily basis) as it interfaces w/ social, political, legal forces and are disturbed by the effect these forces have on clinical decision making.

I understand why it happens, I don't fault individuals, I believe people are doing the best they can in the system they are thrown into (whopper may disagree as he sees many malpractice cases)...but its a problem that I believe our generation of psychiatrists can no longer afford to ignore.

While it was published just before DSM-III, still somewhat relevant 33 years later.

"Psychiatry's identity problems cannot be solved by ignoring them or by becoming more medical."

Gen Hosp Psychiatry. 1979 Jul;1(2):166-73.
Psychiatry's identity crisis: a critical rational remedy.
Manschreck TC, Kleinman AM.

What are our responsibilities? Do we owe it to society to "reduce suffering" (w/ the antihistiminergic effect(s) of a major tranquilizer or two in addition to a mood stabilizer, an SSRI and a BZD) from anxiety because of somebody's "low frustration tolerance" which somehow was medicalized and categorized as "bipolar" because they couldn't be seen w/o an Axis I diagnosis?

Do we critically evaluate information that is given to us or instead do we submit to myriad pressures, cave and fire away w/ a psychopharm regimen for which no evidence exists to support the way it is being used -- and then gets used for further titration chasing god only knows what symptom that ails the patient. Do we really scrutinize critically the limits of our methods and knowledge?

As Nitemagi points out,

The creep follows from symptom-based prescribing without paying attention to the individual as a whole or the context to the symptom. Not every "voice" is psychosis, nor is every "anxiety" requiring meds.

Is there universal risk management training in residency so that we can say "psychotic symptoms are atypical and not suggestive of genuine psychosis thus antipsychotic medication is not indicated currently" when appropriate and document the way OPD suggests we should? Would somebody who chose to prescribe this way be pilloried for their "dogmatic self-righteous non-prescribing" ways? Would they be liable for a bad outcome because the standard of care has been significantly diluted? Could they even find a "respectable minority" in their local area to back them up?

Psychiatry is a great field, best kept secret in medicine as far as I'm concerned.

But...should we just tow the party line because this is what is expected and we don't have a clear image of our identity and are rushed for time? Have we allowed managed care to dictate our identity? Is this acceptable? Can we do better? Is it our moral duty to do better?

I don't know what to do, but ignoring it isn't an option...

 

[Ibid]

As Nitemagi points out,

Is there universal risk management training in residency so that we can say "psychotic symptoms are atypical and not suggestive of genuine psychosis thus antipsychotic medication is not indicated currently" when appropriate and document the way OPD suggests we should? 1.Would somebody who chose to prescribe this way be pilloried for their "dogmatic self-righteous non-prescribing" ways? Would they be liable for a bad outcome because the standard of care has been significantly diluted? 2. Could they even find a "respectable minority" in their local area to back them up?

1. That's what happens.
2. At least in the case below, no.

http://www.timeshighereducation.co.uk/story.asp?storyCode=202721&sectioncode=26