Archive for March, 2013

Toward the New World Order

March 11th, 2013

If the federal health reform initiative proceeds apace, before long almost all Americans will have health insurance. But there are nowhere near enough physicians to care for all of us—especially as the population ages.

Many approaches make sense to enhance the quality and efficiency of our care system—including algorithms, more effective use of extenders, electronic decision support, and patient education. Another feature to come is more selective use of specialists—including psychiatrists.

When care is paid for by a third party, we cannot afford to have many patients cared for primarily by a specialist. The model to come will have specialists create algorithms and protocols for primary care providers (PCPs). Specialists will be available for brief electronic or phone consultations and, less commonly, for one-on-one direct consultation with patients. A psychiatrist will see a patient and refer the patient back to a PCP, with backup as needed. Sometimes we may see the patient for a few visits to ensure stability.

There will always be a small cadre of chronically ill patients who require ongoing care from specialists—brittle diabetics, unstable cardiac patients, and in psychiatry, people who suffer from schizophrenia or bipolar disorder, for example. People who pay out of pocket can call their own tune. But for most Americans, care will have to be more rationalized. I regularly point out to medical students and residents that this will soon change the way we practice and the lives we lead.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

What’s MDD?

March 1st, 2013

I chaired the APA workgroup that authored the third edition of the treatment guideline for major depressive disorder (MDD), published at the end of 2010. MDD is a typical DSM-3 (and beyond) diagnostic category—a behavioral syndrome, which doubtlessly encompasses many biologically distinct diseases. (Hence the varied responses of patients to our ministrations.) But even while we eagerly await the dawning of the era of personalized, genomically informed medicine in psychiatry, we can still assess each depressed patient with a careful differential diagnosis—considering substance abuse, medical and neurologic diseases, and personality disorders, among other possibilities.

This came to mind when a resident presented a case to me. The chief complaints were lack of energy and interest—certainly key components of MDD, but easily reflecting a host of other diagnoses. When I saw the middle-aged man, he had mask-like facies, bradykinetic features, and a resting tremor. On examination he displayed muscular rigidity. We referred the patient to a neurologist, who confirmed a diagnosis of Parkinson disease. The patient’s psychiatric complaints responded favorable to the antiparkinson regimen, as did his motor signs. We will soon taper his SSRI. It didn’t take long, and it sure helped this man.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry