Archive for the ‘Healthcare Reform’ category

Knee-jerk Psychiatry

April 7th, 2013

She was a young woman who’d grown up in an abusive family. Like so many others, she re-created her familiar home environment with a series of abusive partners—bearing children from a number of them. She easily grew frustrated and irritable. Feeling desperate one day, she made a life-threatening suicide attempt and was hospitalized.

 He was a middle-aged man who had built and run a successful business for decades. The business came on hard times, he went into bankruptcy, and his wife left him. He too felt desperate, made a very serious attempt on his life, and also was hospitalized.

In both cases, the serious suicide attempts resulted in a general-hospital stay, followed by transfer to a psychiatric facility. Each patient was diagnosed with a mood disorder, then treated with psychiatric medications—lots of medications. Each was discharged on multiple antipsychotics and antidepressants, a couple of benzodiazepines, gabapentin, and an antihistamine (presumably for additional sedation and anxiety relief).

Within weeks of hospital discharge, each patient showed the adverse effects of these medications: akathisia, parkinsonian signs, substantial weight gain, decreased libido, lipid and glucose abnormalities, and more. The mood-disorder diagnoses seemed questionable to me. More, the cognitive and affective side effects of these complex pharmaceutical regimens made it hard to disentangle preexisting symptoms. The out-patient doctors were challenged in their attempts to establish a therapeutic rapport and help these troubled human beings find new coping strategies in difficult circumstances.

So often what I see around the country is superficial, knee-jerk psychiatry. Harried doctors assume a serious suicide attempt must mean a mood disorder—which is often, but not always true. And a mood-disorder diagnosis (even Depression NOS) and psychiatric admission “demand” medications—often many.

How did we get to this state? Everyone loves to hate insurance companies—except their shareholders and senior executives. Most of us complain about DSM-3 and -4 (and in about a month -5). And medical educators know that Psychiatry often fails to attract the best and brightest medical-school graduates: we don’t get enough respect, our patients are stigmatized, managed care forces us to do short visits, our compensation is low among specialties, etc.

It’s all true. But somehow people in crisis deserve a little time with a knowledgeable, thoughtful professional, who can blend neuroscience with social and psychological dynamics, who brings compassion and wisdom to the clinical encounter. Psychiatry in 2013 has powerful tools. Let’s find a way to employ them with care.

-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

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

Personalize This

January 17th, 2013

The future of psychiatry, and indeed all of medicine, will emerge as we unravel the double helix of the genetic code, the proteins DNA commands, and the epigenetic factors that allow our environment to influence genetic expression. Today, I caught a brief glimpse of that future.

I just attended the ceremonial opening of the Penn State Hershey Institute for Personalized Medicine, one of a handful of high technology centers that will pave the way to a new era in health care. This multimillion dollar facility was enabled by federal, state, and private funds, and the inaugural event was attended by a U.S. senator and many United States, Pennsylvania, and university dignitaries. The Institute consists of laboratories that can quickly and relatively inexpensively map individual genomes, a tissue repository for samples from thousands of patients, and an information technology hub.

When I was a medical student in the 1960s, virtually all children with leukemia died. Today, almost all survive. The difference has been discoveries about the mysteries of individual cancers and how to target treatments to their unique signatures. Not only has survival increased, but when cancer treatments can be personalized, doctors can apply less toxic medicines than the systemic poisons we have used for decades.

I am committing significant discretionary funds from my department to leverage our new center’s technology to achieve breakthroughs in psychiatry. Instead of blasting every cell in the body with increased levels of serotonin, someday we should be able to target interventions to distinct pathophysiology underlying diseases of impulse, mood, and thought. As in other medical specialties, we will bank tissue samples from psychiatric patients, establish diagnoses, track symptoms systematically over time, record responses to treatments, and use computer programs to link biology to pathology and ultimately to cure. It is an exciting time.

-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

When Passion Trumps Practicality

November 19th, 2012

My department at Penn State reaches out regularly to medical students who may be interested in careers in psychiatry: movie nights, mentorship, electives, and much more. A few days ago we held an open question-and-answer lunch, in which three faculty members and a senior resident fielded questions from a couple of dozen students from all four years. We munched on take-out Chinese food and chatted.

One student asked about careers in psychiatry, unmet needs, and subspecialties. He was reasonably trying to sort out his options. I knew that if I told him what had been the facts over my 40 years in practice, and what the world looks like today, he would make his calculations and decision for his practice over the coming 40 years. But the world of U.S. healthcare is anything but static. The changes coming over the next few years will be huge.

I am certain that psychiatry—and our subspecialties even more—will remain short of manpower. But who can say what tomorrow’s psychiatrists will do, what their hours will be, how long they will spend with patients, or what they might earn? I would say the same for the choice of specialty, whether surgery, medicine, pediatrics, or any other. Science and technology will bring major new developments, and the healthcare delivery infrastructure is undergoing a sea change.

What I am sure of is that there will be patients. People will be scared, in pain, confused, and uncertain. They will require ministrations, explanations, treatments, and comfort. The safest course for young doctors looking forward is to follow their passion, to chart their paths by what they most want to do—independent of practical, economic, and lifestyle factors. The joy in medical practice will remain forever—if they can follow their own hearts.

-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

And Now: Healthcare Reform

November 7th, 2012

Last summer the U.S. Supreme Court upheld the Affordable Care Act (ACA). Yesterday’s re-election of President Barack Obama virtually guarantees that ACA will be implemented. The process will be long, complex, with countless moving parts. Many of its features require interpretation, further enabling policies from the HHS Secretary, individual state actions, and a myriad of detailed steps. But the continuing escalation of healthcare costs is unsustainable—especially when we are not buying improved care for our citizens. And we can now see a path forward.

Within a few years, almost all who reside within our borders will be eligible for medical care. Mental and behavioral diagnoses will be covered. With the increased focus on efficiencies, behavior will become paramount: enhancing patients’ understanding of their conditions and care, securing their buy-in to treatments, prompting them (often electronically) to take medicine, come to appointments, and more. Recognizing and effectively treating depression, for example, will improve outcomes and save costs in treating diabetes, heart disease, and many other chronic illnesses. I sincerely hope the chronically mentally ill will begin to receive the medical care that has often been denied them—with safe integration of brain treatments and those for other body organs.

Doctors will experience a sea change. The premium for surgery and invasive procedures will give way to preventive and long-term management foci. Information technology will play a growing role in every aspect of health care. Teams of professionals will be integral in the new order.

It will take a long while to “get it right.” The journey will require patience and efforts at every level. But I am convinced we will get to a better place.

-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

The times they’ll be a-changing

October 18th, 2012

I think the figure I heard yesterday about the amount the United States spends on health care today was $2.6 trillion annually. That’s a lot of zeros! And hard to get my mind around. What it does tell me is that no matter who wins control of the White House and the two chambers of Congress, our current system must and will change dramatically. One expert who addressed our group said that unless the rate of health care cost growth is arrested, the cost of care per employee will exceed wages over the next decade or so. That cannot and will not happen.

Some colleagues advocate for a single-payer system, which might be our ultimate destination. The Affordable Care Act is relatively conservative but will definitely bring big change. Even if conservative forces prevail politically, the market will force change. The change will inevitably involve greater focus on efficiency, effectiveness, evidence-based treatments, and long-term management of patients with chronic illness. Behavioral and psychiatric conditions will ascend in importance. Information technology—for medical records, communication among clinicians and with patients, decision support, and patient education and adherence—will take on growing importance.

Change is inevitable and imminent. Psychiatrists and other physicians must stay attuned and prepared for the implications of change on their lives and practices.

-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

Whither Healthcare Reform?

December 1st, 2011

In multi-specialty groups and integrated academic health systems like mine, psychiatry struggles not to lose money. This economic anomaly stems from a system that biases economic rewards (i.e., gives more money) more for doing things (“procedures”) than for thinking and talking to patients. And it’s not just between specialties, but within: general medicine loses money; procedural subspecialties like cardiology and gastroenterology make money. And a cardiologist, gastroenterologist, or dermatologist, for example, who wants to earn more will devote more time and effort to procedures, shying away from low-reimbursement time with patients.

Care of patients with diabetes mellitus illustrates the dysfunction in America’s healthcare non-system today. Diabetes is a life-long disease. Patients age more rapidly than peers without the disease. Their organs degrade and blood vessels clog. But close monitoring, tight disease management, and behavioral factors like diet and exercise can combat many of these effects and prolong life and function. That’s good for people and saves money. But in our current system, doctors and hospitals aren’t rewarded for these low-tech, long-term, preventative interventions. It’s better for the bottom line to do the many late-stage extensive procedures these patients are likely to require: fixing retinas, bypassing coronary arteries, transplanting kidneys, amputating limbs. And most insurers seek to maximize profits not by cost-effective long-term care and prevention, but by finding ways to encourage people who become sick to leave their programs.

I can’t predict how or when we will see genuine healthcare reform in the United States. But the skyrocketing costs of health expenditures in our country, which buy only mediocre outcomes, dictate that things will need to be fixed and soon. And I have to believe that covering all our people with good health care will demand a cost-effective system, emphasizing prevention and effective long-term care. This, in turn, will require investment and uniformity in information technology, standardization of optimal practice, and—at long last—due attention to behavior. The behavior of our population—whether diet and exercise or compliance with prescribed treatments—is a huge driver of medical costs and an obvious target for attention in the New World Order. I believe that in the system to come, psychiatrists will play a role of great importance, as experts in behavior and specialists in conditions that commonly exacerbate other diseases. Stay tuned.

-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


ACNP Musings

December 8th, 2010

Attending the annual meeting of the American College of Neuropsychopharmacology is always a heady experience. The membership and guests are among the most brilliant humans anywhere, and I am invigorated that so many devote their lives to explicating the brain’s mysteries.

Here in a chilly South Florida, there is much about which to be optimistic. Presenters are young scientists, insuring a continuing pipeline of talent to the labors of cracking the code of brain diseases. And the science and its promise are rich and exhilarating.

But there is fodder for the pessimists and worriers too. Whither healthcare reform, with its promise of extending and rationalizing health care, of stopping discrimination against the mentally ill? And what will happen to the NIH budget, which nourishes the science and scientists on whom we vest our hopes for a better future? Big pharmaceutical companies are pulling back from psychiatric research and products. Where will that leave us over the decades to come?

There is cause for hope. And worry.

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

Cost-effective Mental Health Care

October 4th, 2010

Our college of medicine at Penn State is working with a small number of other medical schools to revise the curriculum so med students will learn to work as members of a healthcare team. In recent years, educators have begun to realize that  we’ve been training doctors to be “lone wolves.” Then the new physicians enter practice and find themselves in an increasingly complex environment with multiple other healing professions. In the curriculum being developed, allied professions include nursing and pharmacy. Psychiatrists often work in teams—with psychologists, social workers, nurses, pharmacists, occupational and physical therapists, and many others.

I keep praying for universal access to health care for all Americans. It is essential that psychiatric care is included. But we don’t have enough psychiatrists (especially those qualified to see children and adolescents) as it is, and universal coverage could exacerbate the shortage. For me, the road to excellent universal mental health care will be based on efficient and cost-effective systems. (And no, I don’t mean asking exhausted clinicians to work faster and harder.)

Good clinical research can serve as a model. It is based on teamwork (beginning with the voice on the phone and face at the front desk). And it requires a protocol. Increasingly, electronics help—capturing data about history, target symptoms, and response to treatment; giving feedback to clinicians; enhancing communications between doctors and patients, family members, and other professionals; and supporting clinical decision making.

The teams we must build involve us with fellow professionals. But we also should include “Robbie the Robot”—i.e., information technology (and someday perhaps actual robots, which already are performing surgery). As psychiatrists, we can’t bring about this grand vision by ourselves, but we can and must have a “seat at the table” and participate in system redesign.

Why I am excited about partnerships

June 8th, 2010

I have spent my career trying to bring together various organizations and factions in a community that share a commitment to helping the mentally ill but don’t historically work together to accomplish that goal. A lot of money and effort is wasted when bureaucrats or community activists protect their fiefdoms at the expense of helping patients.

It’s hard to change that mentality, but well worth it.

When I began my career in Massachusetts, I worked at the Erich Lindemann Mental Health Center, a collaboration among the Commonwealth of Massachusetts, Harvard Medical School, and the Massachusetts General Hospital. Together we built systems of care, research, and education—all to serve people with mental illness.

Later when I moved to Arizona as head of the UA Medical School’s Department of Psychiatry, I reached out to the broader community to form coalitions. We were actually quite successful. We were able to create the Community Partnership of Southern Arizona. And eventually the University of Arizona and our physicians’ group practice partnered with Pima County to build and operate a brand-new psychiatric hospital.

Now that I’m in Pennsylvania, I am working with a wonderfully dedicated group to put strong legs under the fledgling Pennsylvania Psychiatric Institute. I talked a little about it in my last blog.

Partnerships must be the future of medicine in this country. There’s too little money and too great a need to put personal power-building ahead of real progress in medical care for people in serious need.