“Reruns on demand: We can get there legally or illegally.” (MIT Technology Review)

Bush contradicts his own “Roadmap to Peace” by reversing himself on the West Bank settlements, in an attempt to help embattled Israeli prime minister Sharon get his Gaza withdrawal plan past the recalcitrant right wing of his own party. Palestinians have feared all along that the Gaza plan is a cover for reinforcing the Israeli presence on the West Bank.

This April, 2003 report of a blue ribbon federal panel of mental health professionals has recently attracted attention because it is interpreted as proposing an alarming plan to screen the mental health of every American, beginning in the schools. The Bush administration is using the ‘New Freedom’ rubric to refer to a hodge podge of initiatives directed toward people with disabilities; this report maps out the mental health component of the effort. The fact that, as a politically savvy mental health professional, I had never heard of this commission, this report or this initiative may be an indication of how little impact it will have on real mental health practice, but I reviewed the report at the urging of several FmH readers and other webloggers who wanted a professional’s perspective.

Some critics view the screening mandate as a giveaway to the pharmaceutical industry, and place it in the context of the Republicans’ efforts, to paraphrase Bill Moyers, to “privatize public services in order to enrich the corporate interests that fund campaigns and provide golden parachutes to pliable politicians. If unchecked, the result of these machinations will be the dismantling of every last brick of the social contract…. I think this is a deliberate, intentional destruction of the United States of America.” Further alarm is raised by the report’s embrace of “evidence-based” practices and treatment by standardized algorithms exemplified by the Texas Medical Algorithm Project (TMAP). This has been a monumental attempt to reduce medicine to a cookbook approach — if conditions A, B, and C exist, you try treatment X, (which is usually a medication) then if it doesn’t work you go to Y, etc. Treatment guidelines in the algorithms are “evidence-based”, the hot buzzword in clinical medicine (including psychiatry), which is meant to refer to practices proven by research data rather than based on intuition. (I probably don’t need to remind you that most research into treatment outcomes of medications is funded by the pharmaceutical companies that have a vested interest in the findings.) Critics of the TMAP claim that it is driven by a “political/pharmaceutical alliance” for the sole purpose of making newer, expensive, profitable drugs the mainstays of treatment for various disorders. Furthermore, critics claim, Texas officials have reportedly received financial perks from the pharmaceutical industry to influence their adoption of the algorithms. (Let me caution that a critique based on the assumption that drug companies’ contributions are meant to ensure that their drug gets recommended are naive and easily refuted. The pharmaceutical industry usually wields its influence more subtly; by dispensing its largesse to create a warm and fuzzy feeling in the researchers, clinicians and regulators who are worth influencing, rather than as direct bribes.)

Let’s start with the TMAP angle. My reservations about the funding of pharmacological research apart, I have always found algorithm-based medical practice fundamentally flawed. The whole process of identifying what class of patients a given individual falls into, and then treating that individual in a rote manner, seems to ignore crucial aspects of each patient’s uniqueness and the health professional’s need for sensitivity, skill, yes, artistry in applying medical knowledge to the case at hand. This is especially true in the psychiatric field. Thus, the foremost danger of algorithm-based treatment is not that it is a giveaway to Big Pharma. The newer, more expensive medications are used not because they are mandated by algorithms but, simply, because they represent signficant medical advances in efficacy and tolerability. Those of us who scoff at algorithms do not use less of the expensive new medications. The obscenity is not that a government interested in industry giveaways is trying to mandate more expensive drugs as better; it is that it is doing nothing to make better drugs less expensive. Even without algorithms, the pharmaceutical industry already has a captive audience of sick consumers in desperate need on whom it can foist its price-fixing. One of the greatest flaws in the commission report, to my reading, is that the penetration of the drug manufacturers into medical practice is not addressed at all despite an awful lot of highfalutin’ language about making mental health care ‘consumer-driven’ and ‘recovery-based.” In this case, with all due respects to Bill Moyers, it does not appear so much to be a potential windfall for the industry but rather protecting it from a firestorm of criticism that is the Bush administration’s major favor to its friends. It is worth noting, however, the pharmaceutical industry was not overtly represented on the panel, whose members are a large and varied cross-section of the mental health professions, from community mental health practitioners to academics and administrators.

Apart from the algorithmic and “evidence-based” agenda and the screening proposals, the other goals the commission articulates for improving mental health care include reducing stigmatization and enhancing the rights of the mentally ill, achieving parity with physical health care, promoting a national strategy for suicide prevention, promoting comprehensive individual care plans, improving access to mental health services in underserved areas and making mental health care culturally sensitive, improving child psychiatric services and school-based mental health care, improved recognition of the co-occurrence of substance use and mental disorders, shaping research priorities to address clinically useful questions, “develop(ing) the knowledge base in four understudied areas: mental health disparities, long-term effects of medications, trauma, and acute care”, and improving the integration of modern electronic technologies in the delivery of mental health care. In medical school, we are taught to generate a comprehensive ‘problem list’ for each patient we follow. If the patient were the American mental health care system, I am struck by how closely this list gibes with my own problem list. The question is whether there is an action-based agenda to back up the goals, and whether we will put our money where our mouth is.

I have seen too many treatment plans for patients based on comprehensive problem lists in which the plan for problem A is little more than “treat problem A.” In a similar vein, the commission’s verbiage on achieving these goals for the improvement of ailing American mental health care is diffuse and vague. The list includes: educating the public about mental illness to reduce stigmatization; enhancing affordability, access and choice; emphasizing the interconnection of physical and mental health and the coordination of the care of both; a recovery-based model; better alignment of federal mental health policy across agencies, to coordinate health care with the other human needs of mentally ill consumers; community-baase alternatives to institutions; making supported housing and supported employment opportunities more available; improving mental health care in the penal system; meeting specific rural and minority mental health needs; addressing the shortage of personnel in the mental health fields. Yawn. For a specific example of the mind-numbing vagueness that passes for a plan, here are the report’s suggestions for improving acute mental health care (my main interest as an inpatient psychiatrist treating patients with major mental illness during acute crises): “synthesizing the …knowledge base, reviewing the many outstanding model programs…, developing new knowledge as necessary, assessing existing capacities and shortages, and proposing workable solutions.” I know we are supposed to like generics in mental health care, but I thought they were talking about generic drugs, not verbiage!

I usually find “recovery-based” language worrisome, since much mental health care should not be oriented toward an unrealistic goal of curing the patient’s psychiatric illness but helping them stabilize acute symptoms and adapt to what is often a lifelong chronic condition. The commission report counterbalances this with enough attention to mental illness as a lifelong disability and the expectation that consumers will have to negotiate the systems of providing their human needs as mentally ill clients. There is little, however, about the sort of community-based psychosocial rehab, vocational training and social club models that are incredibly useful and humane; nor about the powerful assertive community treatment model to keep our sickest clients in the communities and out of the hospitals. I collaborate enthusiastically with ACT teams around some of the most desperately ill patients I see recurrently in my hospital practice, but they should be providing services to at least three times as many patients as they are able to do.

So, at last, turning to the controversial screening proposals, early identification of and intervention with both at-risk and precociously symptomatic patients, yes, through school- and population-based screening programs, is another area with proven potential to slow or halt the progression to chronicity, and it is another area which is woefully neglected in current mental health practice. The rationale for a school-based focus is at least partially because it is a nonstigmatizing setting a fragile child is already accustomed to, in comparison to hospitals and doctors’ offices. If cases are identified earlier in life and treatment needs, including psychopharmaceutical approaches, are addressed sooner, suffering can be alleviated. Furthermore, the proportion of a child’s social and cognitive demands that occur in the school setting is, of course, enormous, so school-based treatment is community treatment. Screening is no handout to the pharmaceutical industrly unless — and this is a big unless — nothing is done to rectify the current problems with pediatric overdiagnosis, overtreatment and inadequate followup.

By my reasoning, an effective early intervention program would actually alleviate some of these problems. Here’s how it goes. Readers of FmH know that I think the expansion of medication use has been driven not only by the rapacious pharmaceutical industry but by market pressures within psychiatry itself. As MDs have priced themselves out of the market and have been replaced progressively by cheaper non-MD professionals in the delivery of mental health services, the psychiatric profession has been forced to expand the range of conditions it defines as medication-responsive, since psychiatrists are (almost) the only ones who can prescribe. This has ushered in the era of “cosmetic psychopharmacology”, which is fist-in-glove with the dumbing down of psychiatric training to the point that newly-qualified psychiatrists neither see the value of nor have the inclination or skills to do psychotherapy, i.e. communicate effectively, get to know their patients, create a relationship with a patient whose suffering often makes them difficult to reach, and to use that relationship as a healing instrument. If a coherent process exists to match the expansion of the mental health workforce with the expansion of identified treatment needs, my hope is that the market pressure to prescribe needlessly for more trivial conditions will atrophy. It is not likely someone not in the business of delivering mental health services understands how critical the shortage of providers to address pediatric mental health needs is. Children wait days in ERs for a bed in a psychiatric hospital after demonstrating the urgent need; they wait weeks or months to access outpatient services. If screening reprioritizes the focus of care to the truly, urgently sick, and is accompanied by an expansion in manpower, I am all for it. On the other hand, I’m not a health care economist, just a doctor. (When he comes to town, a world-renowned health care economist from Stanford who is a family friend picks my brain on the view from the trenches; I’m going to have to turn the tables the next time I see him — whichshould be next week — and pump him for his reactions to the commission report from a health policy perspective.)

On the other hand, if a national screening agenda is not matched by a dramatic increase in mental health personnel at both the primary care and the referral levels, I am afraid such a program would be carried out through some totally inadequate standardized testing program akin to the standardized educational testing that has become the sole, braindead, standard for ‘leaving no child behind’ educationally. While a robust, individualized and sensitive screening process with adequate personnel and funding could provide early detection and treatment if it focused on at-risk children, those with behavioral problems, and those referred by concerned classroom teachers, the literature shows that standardized, survey-based measures of mental health of entire populations have proven of dubious value when used for epidemiological research purposes, are of no value in targeting clinical interventions, and are too unwieldy to carry out. Again, as in the educational sphere, I can see federal funds for mental health care being tied to state compliance in administering the screening protocols. And, again, as with No Child Left Behind, an unscrupulous Bush or Bush-like administration could comandeer mental health data for other purposes such as military conscription classification. (How would you like to be told that you cannot have a psychiatric deferment from the coming draft, despite the insistence of a sympathetic psychiatrist such as myself that you are mentally unfit to serve, because your childhood psychometric scores ‘proved’ you were across-the-board well-adjusted?)

In short, the report is a puff piece that is not likely to turn into implementable policy. To the extent that it is, I think the concerns about “Bush wanting to be your shrink” are kneejerk alarmism. Although there are a range of issues about which to be concerned in the report, they are not the ones upon which the critics have so far focused. And while, in one alarmist’s turn of phrase, “your first great freedom, the power to control your own thoughts, … (and) your secondary freedom of being able to control the approval for your own medical treatments” are indeed important frontiers of modern freedom, the New Freedom Commission on Mental Health does not represent the immediate threat to them it is made out to be. The greatest problems of the ‘reform’ of the mental health care system proposed by this commission, as I see it, are that it does not address the sellout of psychiatric care to the pharmaceutical industry and the increasing tendencies to conduct treatment in a rote, braindead manner. Even if you had the improved access to mental health services you deserve under this system, you would still end up being treated by someone with little training in or tendency toward creative independent thinking; inadequate familiarity with the range of available (both new and time-honored) treatment options and the possibilities of an individualized and original approach to your problems; and little immunity to having prescribing practices bought and sold by corporate influences. In other words, the problem with the new initiative is not that it will create massive intolerable changes in your care and infringe on your civil rights, as the naive critics propose; rather, it is that it will not change anything. Besides, Ashcroft will not be in charge of the mental health screening, and Bush and his intiiative will be out of office in January in any case, right?

Let the flamewars begin…

This April, 2003 report of a blue ribbon federal panel of mental health professionals has recently attracted attention because it is interpreted as proposing an alarming plan to screen the mental health of every American, beginning in the schools. The Bush administration is using the ‘New Freedom’ rubric to refer to a hodge podge of initiatives directed toward people with disabilities; this report maps out the mental health component of the effort. The fact that, as a politically savvy mental health professional, I had never heard of this commission, this report or this initiative may be an indication of how little impact it will have on real mental health practice, but I reviewed the report at the urging of several FmH readers and other webloggers who wanted a professional’s perspective.

Some critics view the screening mandate as a giveaway to the pharmaceutical industry, and place it in the context of the Republicans’ efforts, to paraphrase Bill Moyers, to “privatize public services in order to enrich the corporate interests that fund campaigns and provide golden parachutes to pliable politicians. If unchecked, the result of these machinations will be the dismantling of every last brick of the social contract…. I think this is a deliberate, intentional destruction of the United States of America.” Further alarm is raised by the report’s embrace of “evidence-based” practices and treatment by standardized algorithms exemplified by the Texas Medical Algorithm Project (TMAP). This has been a monumental attempt to reduce medicine to a cookbook approach — if conditions A, B, and C exist, you try treatment X, (which is usually a medication) then if it doesn’t work you go to Y, etc. Treatment guidelines in the algorithms are “evidence-based”, the hot buzzword in clinical medicine (including psychiatry), which is meant to refer to practices proven by research data rather than based on intuition. (I probably don’t need to remind you that most research into treatment outcomes of medications is funded by the pharmaceutical companies that have a vested interest in the findings.) Critics of the TMAP claim that it is driven by a “political/pharmaceutical alliance” for the sole purpose of making newer, expensive, profitable drugs the mainstays of treatment for various disorders. Furthermore, critics claim, Texas officials have reportedly received financial perks from the pharmaceutical industry to influence their adoption of the algorithms. (Let me caution that a critique based on the assumption that drug companies’ contributions are meant to ensure that their drug gets recommended are naive and easily refuted. The pharmaceutical industry usually wields its influence more subtly; by dispensing its largesse to create a warm and fuzzy feeling in the researchers, clinicians and regulators who are worth influencing, rather than as direct bribes.)

Let’s start with the TMAP angle. My reservations about the funding of pharmacological research apart, I have always found algorithm-based medical practice fundamentally flawed. The whole process of identifying what class of patients a given individual falls into, and then treating that individual in a rote manner, seems to ignore crucial aspects of each patient’s uniqueness and the health professional’s need for sensitivity, skill, yes, artistry in applying medical knowledge to the case at hand. This is especially true in the psychiatric field. Thus, the foremost danger of algorithm-based treatment is not that it is a giveaway to Big Pharma. The newer, more expensive medications are used not because they are mandated by algorithms but, simply, because they represent signficant medical advances in efficacy and tolerability. Those of us who scoff at algorithms do not use less of the expensive new medications. The obscenity is not that a government interested in industry giveaways is trying to mandate more expensive drugs as better; it is that it is doing nothing to make better drugs less expensive. Even without algorithms, the pharmaceutical industry already has a captive audience of sick consumers in desperate need on whom it can foist its price-fixing. One of the greatest flaws in the commission report, to my reading, is that the penetration of the drug manufacturers into medical practice is not addressed at all despite an awful lot of highfalutin’ language about making mental health care ‘consumer-driven’ and ‘recovery-based.” In this case, with all due respects to Bill Moyers, it does not appear so much to be a potential windfall for the industry but rather protecting it from a firestorm of criticism that is the Bush administration’s major favor to its friends. It is worth noting, however, the pharmaceutical industry was not overtly represented on the panel, whose members are a large and varied cross-section of the mental health professions, from community mental health practitioners to academics and administrators.

Apart from the algorithmic and “evidence-based” agenda and the screening proposals, the other goals the commission articulates for improving mental health care include reducing stigmatization and enhancing the rights of the mentally ill, achieving parity with physical health care, promoting a national strategy for suicide prevention, promoting comprehensive individual care plans, improving access to mental health services in underserved areas and making mental health care culturally sensitive, improving child psychiatric services and school-based mental health care, improved recognition of the co-occurrence of substance use and mental disorders, shaping research priorities to address clinically useful questions, “develop(ing) the knowledge base in four understudied areas: mental health disparities, long-term effects of medications, trauma, and acute care”, and improving the integration of modern electronic technologies in the delivery of mental health care. In medical school, we are taught to generate a comprehensive ‘problem list’ for each patient we follow. If the patient were the American mental health care system, I am struck by how closely this list gibes with my own problem list. The question is whether there is an action-based agenda to back up the goals, and whether we will put our money where our mouth is.

I have seen too many treatment plans for patients based on comprehensive problem lists in which the plan for problem A is little more than “treat problem A.” In a similar vein, the commission’s verbiage on achieving these goals for the improvement of ailing American mental health care is diffuse and vague. The list includes: educating the public about mental illness to reduce stigmatization; enhancing affordability, access and choice; emphasizing the interconnection of physical and mental health and the coordination of the care of both; a recovery-based model; better alignment of federal mental health policy across agencies, to coordinate health care with the other human needs of mentally ill consumers; community-baase alternatives to institutions; making supported housing and supported employment opportunities more available; improving mental health care in the penal system; meeting specific rural and minority mental health needs; addressing the shortage of personnel in the mental health fields. Yawn. For a specific example of the mind-numbing vagueness that passes for a plan, here are the report’s suggestions for improving acute mental health care (my main interest as an inpatient psychiatrist treating patients with major mental illness during acute crises): “synthesizing the …knowledge base, reviewing the many outstanding model programs…, developing new knowledge as necessary, assessing existing capacities and shortages, and proposing workable solutions.” I know we are supposed to like generics in mental health care, but I thought they were talking about generic drugs, not verbiage!

I usually find “recovery-based” language worrisome, since much mental health care should not be oriented toward an unrealistic goal of curing the patient’s psychiatric illness but helping them stabilize acute symptoms and adapt to what is often a lifelong chronic condition. The commission report counterbalances this with enough attention to mental illness as a lifelong disability and the expectation that consumers will have to negotiate the systems of providing their human needs as mentally ill clients. There is little, however, about the sort of community-based psychosocial rehab, vocational training and social club models that are incredibly useful and humane; nor about the powerful assertive community treatment model to keep our sickest clients in the communities and out of the hospitals. I collaborate enthusiastically with ACT teams around some of the most desperately ill patients I see recurrently in my hospital practice, but they should be providing services to at least three times as many patients as they are able to do.

So, at last, turning to the controversial screening proposals, early identification of and intervention with both at-risk and precociously symptomatic patients, yes, through school- and population-based screening programs, is another area with proven potential to slow or halt the progression to chronicity, and it is another area which is woefully neglected in current mental health practice. The rationale for a school-based focus is at least partially because it is a nonstigmatizing setting a fragile child is already accustomed to, in comparison to hospitals and doctors’ offices. If cases are identified earlier in life and treatment needs, including psychopharmaceutical approaches, are addressed sooner, suffering can be alleviated. Furthermore, the proportion of a child’s social and cognitive demands that occur in the school setting is, of course, enormous, so school-based treatment is community treatment. Screening is no handout to the pharmaceutical industrly unless — and this is a big unless — nothing is done to rectify the current problems with pediatric overdiagnosis, overtreatment and inadequate followup.

By my reasoning, an effective early intervention program would actually alleviate some of these problems. Here’s how it goes. Readers of FmH know that I think the expansion of medication use has been driven not only by the rapacious pharmaceutical industry but by market pressures within psychiatry itself. As MDs have priced themselves out of the market and have been replaced progressively by cheaper non-MD professionals in the delivery of mental health services, the psychiatric profession has been forced to expand the range of conditions it defines as medication-responsive, since psychiatrists are (almost) the only ones who can prescribe. This has ushered in the era of “cosmetic psychopharmacology”, which is fist-in-glove with the dumbing down of psychiatric training to the point that newly-qualified psychiatrists neither see the value of nor have the inclination or skills to do psychotherapy, i.e. communicate effectively, get to know their patients, create a relationship with a patient whose suffering often makes them difficult to reach, and to use that relationship as a healing instrument. If a coherent process exists to match the expansion of the mental health workforce with the expansion of identified treatment needs, my hope is that the market pressure to prescribe needlessly for more trivial conditions will atrophy. It is not likely someone not in the business of delivering mental health services understands how critical the shortage of providers to address pediatric mental health needs is. Children wait days in ERs for a bed in a psychiatric hospital after demonstrating the urgent need; they wait weeks or months to access outpatient services. If screening reprioritizes the focus of care to the truly, urgently sick, and is accompanied by an expansion in manpower, I am all for it. On the other hand, I’m not a health care economist, just a doctor. (When he comes to town, a world-renowned health care economist from Stanford who is a family friend picks my brain on the view from the trenches; I’m going to have to turn the tables the next time I see him — whichshould be next week — and pump him for his reactions to the commission report from a health policy perspective.)

On the other hand, if a national screening agenda is not matched by a dramatic increase in mental health personnel at both the primary care and the referral levels, I am afraid such a program would be carried out through some totally inadequate standardized testing program akin to the standardized educational testing that has become the sole, braindead, standard for ‘leaving no child behind’ educationally. While a robust, individualized and sensitive screening process with adequate personnel and funding could provide early detection and treatment if it focused on at-risk children, those with behavioral problems, and those referred by concerned classroom teachers, the literature shows that standardized, survey-based measures of mental health of entire populations have proven of dubious value when used for epidemiological research purposes, are of no value in targeting clinical interventions, and are too unwieldy to carry out. Again, as in the educational sphere, I can see federal funds for mental health care being tied to state compliance in administering the screening protocols. And, again, as with No Child Left Behind, an unscrupulous Bush or Bush-like administration could comandeer mental health data for other purposes such as military conscription classification. (How would you like to be told that you cannot have a psychiatric deferment from the coming draft, despite the insistence of a sympathetic psychiatrist such as myself that you are mentally unfit to serve, because your childhood psychometric scores ‘proved’ you were across-the-board well-adjusted?)

In short, the report is a puff piece that is not likely to turn into implementable policy. To the extent that it is, I think the concerns about “Bush wanting to be your shrink” are kneejerk alarmism. Although there are a range of issues about which to be concerned in the report, they are not the ones upon which the critics have so far focused. And while, in one alarmist’s turn of phrase, “your first great freedom, the power to control your own thoughts, … (and) your secondary freedom of being able to control the approval for your own medical treatments” are indeed important frontiers of modern freedom, the New Freedom Commission on Mental Health does not represent the immediate threat to them it is made out to be. The greatest problems of the ‘reform’ of the mental health care system proposed by this commission, as I see it, are that it does not address the sellout of psychiatric care to the pharmaceutical industry and the increasing tendencies to conduct treatment in a rote, braindead manner. Even if you had the improved access to mental health services you deserve under this system, you would still end up being treated by someone with little training in or tendency toward creative independent thinking; inadequate familiarity with the range of available (both new and time-honored) treatment options and the possibilities of an individualized and original approach to your problems; and little immunity to having prescribing practices bought and sold by corporate influences. In other words, the problem with the new initiative is not that it will create massive intolerable changes in your care and infringe on your civil rights, as the naive critics propose; rather, it is that it will not change anything. Besides, Ashcroft will not be in charge of the mental health screening, and Bush and his intiiative will be out of office in January in any case, right?

Let the flamewars begin…