Keep Sound Minds

In 2008 I blogged about how after Marci Thibault, in a state of psychosis, walked into New Hampshire traffic with her twin sister Danielle's two young children, killing them all, Danielle and her husband Ken formed a not-for-profit devoted to "prevent[ing] similar incidents from occurring by improving society's understanding and management of mental health issues."

Keep Sound Minds, the organization Danielle and Ken founded, is hosting an event in Woburn, Massachusetts, on Saturday evening May 18. I have the privilege of being one of the speakers, along with Ken and Danielle. The event is co-sponsored by the Wellstone-Barlow Mental Health Initiative. David Wellstone is son of the late Senator Paul Wellstone, who crusaded for mental health causes. Ken Barlow is a popular TV meteorologist in Minnesota who recently "came out" about having bipolar illness. (See here for a great interview with him.) Their organization is devoted to de-stigmatizing mental illness. David Wellstone and Ken Barlow will also speak.

I encourage readers to go to the Keep Sound Minds website and to watch the interview with Ken Barlow. And, if you're in the area, come to the event on May 18th and tell folks you know who have a special interest in mental health matters about it.

The Bias Towards Drugs in Psychiatry

Two days ago I posted about the bias towards drugs in treating depressed older patients. The next day the New York Times published a heartbreaking op ed on the same theme by Ted Gup, whose son died of a drug overdose 18 months ago.

Gup reflects with pain on his decision to allow his son to be put on stimulants for what was diagnosed as ADHD. In retrospect, he feels he contributed to his son's ultimate death:

In another age, David might have been called "rambunctious." His battery was a little to large for his body. And so he would leap over the couch, spring to reach the ceiling and show an exuberance for life that came in brilliant microbursts...

No one made him take the heroin and alcohol, and yet I cannot help but hold myself and others to account. I had unknowingly colluded with a system that devalues talking therapy and rushes to medicate, inadvertently sending a message that self-medication, too, is perfectly acceptable.

I had the good luck to have been allowed to outgrow my rambunctiousness. I remember my elementary school report card identifying "self control" as a "special need." I remember as well not understanding why it bothered my parents that when I spoke with them I went through the motions of a baseball pitcher. "Ants in your pants" was the "diagnosis" they gave me. After some years, the ants disappeared. The key interventions came from wise parents, teachers, and sports coaches.

Gup sees how the culture that contributed to the death of his son affects us at every stage of life:

I fear that being human is itself fast becoming a condition. It’s as if we are trying to contain grief, and the absolute pain of a loss like mine. We have become increasingly disassociated and estranged from the patterns of life and death, uncomfortable with the messiness of our own humanity, aging and, ultimately, mortality...Instead of enhancing our coping skills, we undermine them and seek shortcuts where there are none, eroding the resilience upon which each of us, at some point in our lives, must rely.

The young move too fast for our comfort and we give them drugs to slow them down. The elderly move too slowly for our comfort and we give them drugs to speed them up.

The Bias Towards Drugs in Treating Depressed Older Patients

I recently read an article on "How to adapt cognitive-behavioral therapy for older adults" that came to me in Current Psychiatry, a "throw-away" journal (one that comes to professionals free of charge and without subscription, typically containing non-peer-reviewed articles and often replete with advertising). The article itself was excellent, but the opening paragraph was revealing in terms of the problematic way psychiatric treatment is typically framed nowadays:

Some older patients with depression, anxiety, or insomnia may be reluctant to turn to pharmacotherapy and may prefer psychotherapeutic techniques. Evidence has established cognitive-behavioral therapy (CBT) as an effective intervention for several psychiatric disorders and CBT should be considered when treating geriatric patients. (emphasis added by me)

Perhaps as the spouse of a college English teacher I'm overly fussy about language, but to my eye this paragraph gives drugs the position of privilege in treating elderly patients with the common symptoms of depression, anxiety, or insomnia, and relegates psychological interventions like CBT to "be considered" if drugs are rejected. Readers wouldn't guess that the National Institute for Health and Clinical Excellence (NICE) guideline on treating depression in adults recommends various applications of CBT as the first intervention for subthreshold depressive symptoms or mild to moderate depression. Drugs only come in later (except for more severe depression)!

Outcome studies suggest that CBT is at least as effective as medication for mild to moderate depression. Given that medication side effects can be especially problematic in an elderly population, why the bias against psychosocial interventions? I see four main reasons:

1. From non-stop pharmaceutical marketing to physicians and the public, we associate drugs with images of butterflies, sunshine, smiling faces, and other seductive visions. The multi-billion dollar marketing campaign synergizes with our wish for quick and easy fixes to our problems.
2. Ageism, as reflected in aphorisms like "you can't teach an old dog new tricks," promotes the belief that elderly folks are too set in their ways to change by psychological means. Empirical studies show this isn't true.
3. Non-mental health clinicians may worry that they aren't adequately skilled at providing CBT or other psychosocial interventions like my primary care colleague years ago who said, in unintended verse: "I know what to do when they're dying/But not what to do when they're crying."
4. For harried primary care physicians (the likeliest group to see elderly patients with mild depression) writing a prescription takes much less time than initiating a psychosocial intervention.

Lack of skill and the crunch of time are serious impediments. But they're not insoluble. CBT has been adapted to self-guided formats. Non-mental health clinicians and aides have been trained in basic CBT approaches. And CBT has been delivered by telephonic means.

The degree to which we favor drugs over psychosocial treatments ultimately reflects a form of bias. That's why I discuss it in a blog about ethics!

(For an example of how our national tilt towards mechanistic thinking about human process affects another age group, see yesterday's New York Times article reporting that 11% of school aged children have been given a diagnosis of ADHD. Stimulants represent a nine billion blockbuster business.)

Badmouthing Your Doctor

A headline on the front page of this morning's Boston Globe jumped out at me - "Doctors fire back at patient critiques: Lawsuits target harsh web posts." It tells the painful story of the relationship between Gary Cotour and Dr. Sagun Tuli, neurosurgeon for his late wife Lyn.

Dr. Tuli operated on Lyn Votour to remove cancerous vertebrae. During the second surgery Ms. Votour experienced a stroke. After a stay at a rehabilitation hospital she returned home, bedridden and dependent on a feeding tube. Two years later, depressed and in pain, Lyn Votour asked Gary to remove her feeding tube. He did so, and she died.

Mr. Votour's relationship with Dr. Tuli apparently went well during her acute hospitalization, but after discharge it fell apart. After her death Mr. Votour asked to meet with Dr. Tuli. Here's what he later said about the situation:

I was not doing well with grief. I wanted to go back and talk to Dr. Tuli about some questions that were bothering me. I really wanted to ask her why don’t doctors follow up after discharge. I wanted to understand why doctors just wash their hands after discharge.

The meeting Mr. Votour wanted never happened. Dr. Tuli claims that a hospital lawyer told her not to meet with Mr. Votour. The hospital denies this and claims that Dr. Tuli "indicated that she was not comfortable meeting with Mr. Votour."

Mr. Votour posted on his blog that doctors at the rehabilitation facility had encouraged him to file a malpractice suit against Dr. Tuli and that he lost his wife "not to cancer but to indifference and egotism."

In response, Dr. Tuli is suing Mr. Votour for defamation, asking for $100,000 in damages.

Whether it was the hospital lawyer's advice or Dr. Tuli's discomfort that led to not meeting with Mr. Votour after his wife's death, that meeting should have occurred. In addition to all of the work that has been done on the benefitial effects of apology, I draw on a personal experience here. Some decades ago I had brief contact with a college age student suffering from severe depression. The student believed that the depression stemmed from stressors, and that returning to school would alleviate the symptoms, as had occurred in the past. After discussion, I agreed with this prediction, but advised the student (I'm deliberately leaving out gender and other identifiers) to seek immediate help if the symptoms recurred. The symptoms did recur. The student sought help as I had advised, but committed suicide in the course of the care process.

The student's family asked to meet with me. We met for an hour or two. They pressed me to explain why I supported return to college rather than immediate hospitalization. After I did so they asked if I felt I had made a mistake. I said that I had thought carefully about the advice I'd given, but that in retrospect I wished I had followed a different course. I expressed my great sorrow about the student's death. It was one of the most painful meetings of my entire career.

Some years later I was contacted by a malpractice lawyer representing the family. My anxiety soared. The lawyer asked me for information, but told me that the family was bringing suit against the college, and had specifically requested that I not be brought into the case.

Given the terrible outcome it would have been entirely understandable for me to have been sued. I believe the heart to heart meeting we had had after the student's suicide assuaged potential bitterness against me. The family may well have felt that I made an erroneous judgment, but they did not feel as Mr. Votour did that the student's death was caused by "indifference and egotism."

The Boston Globe article quotes David Ardia, codirector of the Center for Media Law and Policy at the University of North Carolina, about the impact of the Internet on physician concern about our reputations: 

the Internet has realigned the power structure that existed between doctors and patients, giving patients far more influence than they have ever had. The Web is just chock-full of people commenting on their experiences. Doctors have reacted with a great deal of hostility toward this.

The article led me to look myself up on the rate-your-physician sites. The single patient response on healthgrades gave me the lowest possible grades on every category. I ended my clinical practice five years ago, but if I were still in practice I'd be concerned that 100% of the reviews I'd received gave me a F grade.

Dr. Tuli's suit against Mr. Votour reflects a classical form of "good vs good" ethical conflict. Freedom of speech is a fundamental good, enshrined in the First Amendment. But our public reputations are precious to us, and even a non-verbal critique like the one an anonymous former patient gave me on healthgrades can undermine a career. As unseemly as it is for a physician to sue a former patient, Dr. Tuli will not be the last physician to follow that unhappy route.

(Two examples of enterprises that offer to protect physician reputations can be seen here and here. And, thanks to an anonymous reader, here is a link to the original post that is no longer on the web.)

A Personal Experience with Medical Cost Containment

When I saw my primary care physician earlier this week he gave me a pep talk about scheduling the colonoscopy I'd been dawdling on doing. I decided it was time to follow his advice.

I had two reasons for being concerned about how much the colonoscopy would cost. First, from the self-centered perspective, my insurance includes a $1500 deductible, so I would be paying some or all of the cost on my own nickel. Second, from the perspective of a concerned citizen, I believe we all have a moral responsibility to (a) take care of our health (b) at the lowest cost to collective insurance funds. If the test cost more than my deductible my fellow insurees will be paying for my charges, and I should consider their financial well-being just as I consider my own.

I'd recently received notice that my self-insured employer offers a service called SaveOn, provided by Tandem Care, a five year old New Hampshire company that gives patients comparative cost information on services within their insurance network. If we're already scheduled to go to a "low cost" provider, we get a $10 reward simply for having called the SaveOn program. If we're scheduled for a high cost provider and choose to go to a lower cost provider instead, we get a reward of $25 to $75, depending on the cost of the procedure.

I receive my care from Harvard Vanguard Medical Associates, a large non-profit, multi-specialty group practice in Massachusetts. I preferred to have the colonoscopy done at the HVMA facility. Doing so would ensure the best coordination of information flow and followup. But suppose an alternative of good enough quality cost $500 less? Would coordination be worth that much additional cost to me?

I called the SaveOn service with some trepidation. The service itself was excellent. A nurse answered my call after one ring. She took my information efficiently and called me back within 15 minutes. Happily, the site I'd been referred to within the group practice was considered a "low cost provider." That spared me the challenge of (a) deciding how much additional cost continuity of care was worth to me and (b) chiding my medical team for being "high cost." The SaveOn nurse told me I'd receive a $10 check after the procedure was done.

Within the cockamamie U.S. health "system," Tandem Care/SaveOn are providing a valuable service. In our consumer role it helps us take care of ourselves at a lower cost. Even if our insurance does not include a deductible - something that is increasingly rare nowadays - the reward for choosing a lower cost provider is enough to matter to us. In our citizen role the program helps us reduce overall costs to the body politic, and, at the same time, educates us to think about costs in health care as we do in virtually every other aspect of our lives.

For decades, we in the U.S. have been searching desperately for ways to make health care less costly. None of the gimmicks we try will work unless we citizens embrace the effort. If we had a national system with a budget paid for via our taxes the way most other developed countries do we'd be invested in getting the most bang for our bucks. But in the highly fragmented "system" we have, the relationship between overall costs and the choices we make as individuals is largely invisible to us. My little experience with SaveOn shows how smart systems can help to make us less stupid about costs!

Beef: The REAL Health Food

Update - Sten made me aware that the timing between the slides and the audio fails at the 31 minute mark. I am preparing a corrected version. I'll upload it as soon as I can, and re-post the link.

Update 2 - Corrected versions are posted to Vimeo and YouTube. 

I was invited to participate in the joint Maryland Cattle Industry Convention and Hay & Pasture Conference. My visit to Hagerstown was quite enjoyable. I met a number of folks and I learned a great deal.

I gave two presentations: “Optimizing Forage-Based Animal Nutrition” and “Beef: The REAL Health Food!” I meant to record both of them, but I forgot to turn on my Zoom H2 for the animal nutrition presentation. [slaps forehead]

I’ve produced a “video” of the Beef presentation. It’s a combination of an audio recording with the PowerPoint slide set.

 

Using the Web to Improve Care for Depression

I've imagined that if I were starting my career in psychiatry now I'd work at the intersection of clinical care and the web. A recent article on "Web-Delivered Care Management and Patient Self-Management Program for Recurrent Depression: A Randomized Trial" convinces me to stick with my fantasy about what I'd do if reincarnated.

The project was conducted at The Permanente Medical Group in Northern California. Patients with chronic or recurrent depression were invited to participate in a randomized trial of usual care compared to usual care plus a web-based care management and patient self-management program that was available for 12 months. The web program included self-monitoring tools, secure messaging with a nurse care manager, depression education stressing cognitive behavioral methods, a monitored discussion group, a personal database, task lists, and an appointment calendar. Interviewers blind to the treatment condition interviewed the patients at 6,12, 18 and 24 months. Participants could enlist a "care partner" for whom web-based materials were also available.

The outcomes were impressive. The "experimental" group had significantly greater reduction in depression that lasted through the year after the web-based intervention ended. They had more confidence in their ability to cope with the mood disorder and more satisfaction with their care. The intervention itself cost $345 per participant. The nurse care manager logs indicated that a nurse could manage 200 patients in ten hours a week. There was no difference in total medical costs between the two groups.

So why do I write about this on an ethics blog?

In 1994 I was asked to edit a quarterly column about managed care for the American Psychiatric Association journal Psychiatric Services. (I edited and wrote the column for ten years.) Readers probably wanted to read about the evils of managed care, but I felt there was more than enough managed care bashing available, and chose to develop columns on how to manage care in ways that were clinically informed and ethically admirable. My underlying belief was, and is, that managed care, "appropriately" conducted, is the most ethical way to structure a health care system.

The e-care program at Kaiser Permanente took evidence-based components of effective treatment for depression and "re-engineered" them into an efficient web-based format. The medical group carried out the intervention and studied it in a rigorous manner. Their work combined clinical innovation with development of valuable new knowledge. The intervention appears to deliver more benefit at no increase in cost. "Benefit" is a bland word, but anyone who has experienced depression or is close to someone who has knows how much suffering the condition can entail.

There's an ethical imperative for us clinicians to evaluate what we do in order to make treatment more effective and efficient over time. That's what the team at Kaiser Permanente and their colleagues did. It would have been clinically and ethically acceptable for them to have implemented the program without studying its results, but they conducted research along with implementing the program. As a result, we're smarter and have new tools for making treatment better. That's why I write about their work in an ethics blog!