John J. Miller, MD

COVID-19 rewrote—and continues to rewrite—the rules as to how medicine can be delivered. Like many of you, I spent the first 14 or so months of the pandemic exclusively engaged in 

, working out of my home. However, as soon as our clinic reopened to in-person patient appointments with rigorous safeguards in place, I returned to that setting. In fact, I was—and frankly remain—befuddled as to how few clinicians, both at our clinic and across the country, have returned to providing in-person treatment when the option to practice virtually continues to exist for them.

Don’t miss your opportunity to chat with John J. Miller, MD, at the 

American Psychiatric Association Annual Meeting

12:00pm to 2:00pm on Monday, May 23, 2022, at the 

Fortunately, many of my patients returned to in-person visits right away, and when we meet in the waiting room for the first time since the pandemic started, it is a welcome reunion. In my experience, so much more clinical information is accessible and treatment planning is more easily negotiated. Loose ends from the telemedicine days can be quickly tied up.

Still, some patients prefer telemedicine. Each of the 20 or so patients I am scheduled to see a day are given the option to meet in person, on the doxy.me virtual platform, or by voice only over the telephone. It has been fairly consistent over the past 10 months: About a third attend in person, a third I meet with on doxy.me, and a third I meet over the telephone. I have read studies that consistently conclude patients and clinicians are equally or more satisfied with their virtual treatment option than meeting in person. There are likely many reasons for this: no need to travel to the appointment; the ability to wait at home if the clinician is running late rather than waiting in a busy/noisy waiting room; lower no-show rates, which greatly improve clinician productivity; the clinicians’ ability to work from home, eliminating the stress of commuting to work; no need to rent office space; greater ease ending an appointment than in person, and more.

Maybe I am just old fashioned. I enjoy and learn a lot clinically when I walk out to the waiting room to meet my next patient. In that moment of eye contact and recognition, I usually have a good sense as to how they are doing. I observe their energy level, posture, body tension, unusual movements, hygiene, smell, and overall presence as I walk behind them to my office. And, after practicing virtually for 14 months, it has been refreshing to be face to face in the same room to explore my patient’s challenges, stressors, achievements, progress, and fears, and genuinely be present in a way that is not possible through telemedicine.

Let me be clear: I am delighted over the impressive and exponential advancements that have developed in telemedicine over the past 2 years. I support and appreciate the growth in the telemedicine arena, which has greatly improved access for patients who had significant treatment roadblocks due to geographic distance and isolation, institutional deficits in necessary clinicians, transportation issues, health conditions that prevented or required avoidance of hospitals and clinics, and many other barriers. Through virtual platforms, expert consultants are now available to assist hospitals and clinics that lack the resources to hire the wide range of specialists who are commonplace at major medical centers. Innovators are broadening options to enhance access for populations in need of virtual access. During the pandemic, many of my patients were perfectly happy having our scheduled appointments by voice only over the telephone. Remarkably, no-shows and canceled appointments dropped to close to zero.

Yet it was not ideal. I remember the many times when my patients’ inadequate cellular or internet connection interfered with our ability to meet satisfactorily. I had to recommend parking near a Starbucks or Panera to use their wireless network to some of my patients for our next virtual appointment.

In addition, some patients whispered to me that they could not really talk openly, as their partner, roommate, or child was in the room or within hearing distance. I rarely received results from the lab orders I mailed to the patient after the virtual appointment. I had “appointments” with patients at checkout lines in stores, taking a walk with a friend, or while they were in waiting rooms for some other appointment. I lost the intuitive sense that had developed after 8 years of medical school and residency and 30 years of in-person clinical practice that would often provide significant insight into my assessment and treatment planning.

After all, sitting in my office with a patient allows for much communication, especially through our mutual eye contact. Sometimes sitting in silence and gazing into each other’s eyes creates a powerful therapeutic moment. The eyes are a special sensory door for us humans and can facilitate quite a range of emotions, including fear, paranoia, acceptance, joy, and relief.

That is why I am now concerned that telemedicine is, unfortunately, metastasizing into clinics and settings where the option to meet in person is readily available. This is a dangerous evolution away from in-person treatment. Our brains are wired to engage in a 4-dimensional environment using all of our sense modalities. I cannot imagine a parent raising their child virtually or spending the majority of time in a relationship with a loved one or friend virtually. I am not interested in virtual vacations. Scuba diving or hiking on a digital screen or over a telephone, for that matter, does not sound appealing.

Medicine is a healing profession. Qualities like empathy, compassion, acceptance, “sitting” with our patient’s pain and suffering, listening to a traumatic life story, discussing treatment options, being present and attentive to our patients in a way that they feel it, and breathing the same air in the same room and in the same moment while looking at their soul through the windows of their eyes are qualities that are greatly diluted and often absent through a virtual platform. 

is medical director, Brain Health, Exeter, New Hampshire; Editor in Chief, 

; staff psychiatrist, Seacoast Mental Health Center, Exeter; Consulting Psychiatrist, Exeter Hospital, Exeter; consulting psychiatrist, Insight Meditation Society, Barre, Massachusetts.

Articles

There have been many exciting advances in telemedicine in recent years. But does telemedicine really allow us to be genuinely present for our patients?

A Dangerous Evolution?

Through the past 2 years of the COVID-19 pandemic, time has become amorphous. Events that occurred in the past month or two feel like they happened long ago. Memories of distant experiences feel more recent. This warping of the sense of time hit home to me recently as we at 

 and Physician’s Education Resource®, LLC, began planning our 2022 Annual 

 World CME Conference™, scheduled August 11-13, 2022, in San Diego, California. Last year’s conference, which was in early October, feels like it took place years ago.

Contributing to the time warp is the fact that the past 2 conferences, both initially scheduled to be live in San Diego, ended up being virtual. Despite not having a crystal ball, I am hopeful that this year’s conference will be a live event. Attending an in-person conference amplifies the experience: the palpable energy in the room during a presentation; the side conversations that enrich the topic at hand; mingling with friends and colleagues, old and new; informal gatherings that strengthen collegiality and our shared purpose; and having time to explore the richness of San Diego, which offers something for everyone.

Responding to the feedback from attendees of the past 2 virtual conferences, we will also offer attendance virtually, which allows clinicians who otherwise would not be able to attend to participate in the rich and comprehensive curriculum. Virtual attendees can submit questions to our expert faculty and will earn the same 14.5 CME credits as live attendees. It is likely that this hybrid model for conferences, which mirrors how we are practicing psychiatry, will remain as the “new normal.”

Our beloved profession of psychiatry continues to rapidly evolve. The conference’s signature format of 20-minute presentations allows for coverage of a range of topics to maximize the learning experience and provide a thorough update of important advances. I encourage you to explore our conference schedule at 

. As always, ample time will be provided for questions from participants to the faculty for each subsection of the conference.

I look forward to spending time with you, our readers, and hearing your thoughts and feedback on how we can improve 

 to continue our mission to provide timely, practice-oriented, and peer-reviewed content—our foundational purpose since the inception of 

 in 1985. As I write this sitting in my home office in Exeter, New Hampshire, in late February, the day after a 1-foot snowstorm and a frigid 15 degrees outside, I close my eyes and imagine sitting outside, overlooking the Pacific Ocean with a warm breeze filling the air, the sun massaging my body, and I revel in how good it will be to be back in San Diego.

The 2022 Annual Psychiatric Times World CME Conference is coming in August.

Learn With Us in San Diego

John J. Miller, MD, discusses tardive dyskinesia and movement disorders. 

is medical director, Brain Health, Exeter, New Hampshire; Editor in Chief,

; staff psychiatrist, Seacoast Mental Health Center, Exeter; Consulting Psychiatrist, Exeter Hospital, Exeter; Consulting Psychiatrist, Insight Meditation Society, Barre, Massachusetts.

Videos

Take a look at the 4 primary movement disorders commonnly encountered in psychiatry when antipsychotics are prescribed. 

Movements in the 4th Dimension 

John J. Miller, MD, discusses how to engage patients in psycheducation and the importance of patient discussion. 

How can you empower the patient to be part of the discussion surrounding their treatment? 

Patient Discussion and the Importance of Continuous Patient Education

The American Psychiatric Association is publishing its next iteration of 

: DSM-5-TR. It feels like a lot less than 9 years since the publication of 

, but I remember how disorienting it was when it came out. I am still grieving the loss of the 5 axes from the previous DSMs, and I would reinstate them in a heartbeat. Maybe this grief is somehow related to the newly added 

. This term will apply to individuals experiencing a persistent grief response that meets specific criteria and has lasted for at least 12 months for adults and at least 6 months for children and adolescents.

," where John J. Miller, MD, shares the history of the DSM.

However, to be fair, mood disorder NOS (not otherwise specified) has been resurrected with the DSM-5 congruent name of 

. This is a big deal. It is challenging and often premature after an initial psychiatric evaluation to have to choose between unipolar major depression and bipolar major depression as the primary diagnosis, as all too often it takes time to tease these apart. Unspecified mood disorder allows us to identify that our treatment is targeting a mood disorder while simultaneously providing us with the clinical flexibility to treat this mood disorder without etching into a patient’s electronic medical record that it is unipolar or bipolar.

Two significant additions to the chapter “Other Conditions That May Be a Focus of Clinical Attention” are a history or the current presence of 

. These are welcome additions, as we will now be able to codify the intent of self-injurious behaviors. This will contribute important information in the patient’s medical record to assist in the determination of harm assessment, especially by a clinician who does not know the patient. For some patients, there can be a bidirectional movement between suicidal and nonsuicidal behaviors over time, ultimately resulting in the codification of both descriptors.

A welcome change is the almost complete elimination of the term 

, which was first used in 1955 to describe the effects of the first antipsychotic, chlorpromazine. The term neuroleptic was derived from the Greek words that translate to “take hold of nerves,” and it reflected the observation of adverse effects of early antipsychotics, which included decreased activity, sedation, and impaired motor function. I have always viewed neuroleptic as an archaic term that should have been retired from psychiatric nomenclature decades ago. In DSM-5-TR, it will only remain with the diagnosis 

. In its place, 2 different terms are used depending on the disorder: antipsychotic or dopamine receptor blocking agent.

I long for the day when we transition over to neuroscience-based nomenclature in which a drug is defined by its mechanism of action and not by what disorder it treats. In my opinion, even the term 

 is not specific enough. There are 5 main dopamine receptor families, each with subsets of variations. Dopamine receptor 1 (D1) and dopamine receptor 5 (D5) both increase the postsynaptic intracellular synthesis of the secondary messenger cyclic adenosine monophosphate (cAMP) when the neurotransmitter dopamine binds to them. In sharp contrast, dopamine receptors 2, 3, and 4 all decrease cAMP synthesis in the postsynaptic neuron and hence are oppositional to D1 and D5. Significantly, dopamine’s binding affinities for D1, D2, and D3 are dramatically different, as are their locations in various brain regions and circuits. Dopamine binds approximately 10 times tighter to D3 receptors than to D2 receptors, and 30 times tighter to D3 receptors than to D1 receptors.

, we really are not providing specific information about the neuropharmacology involved. My preference is to differentiate the specific dopamine receptor that is in play by a drug, which often varies by serum level of that drug. Hence, drugs that are dopamine-2 receptor blocking agents are believed to be involved in psychosis, mania, prolactin levels, tardive dyskinesia, acute dystonias, and drug-induced parkinsonism. The plethora of published research on the dopamine system supports this specific characterization of the D2 receptor.

One of the benefits of having a DSM of mental disorders—which is updated on a regular basis in an attempt to reflect our evolving understanding of the brain’s functioning, individual variability, and dysfunction—is to share a common diagnostic manual for clinicians and investigators. Having a shared frame of reference for a specific constellation of signs and symptoms allows for a common language that theoretically allows for more rapid advancements in understanding mental disorders, as well as improved guidelines and algorithms for treatment.

The cautionary note is that each DSM edition is only a reflection of the American Psychiatric Association’s agreed-upon opinion at the time a new edition is published and will be in constant flux and revisions for decades to come. There are immense limitations and collateral damage that result from clinicians, insurance companies, and policy makers who impose intrusions into our care of patients based on the mythical belief that the DSM is scientific dogma and fact.

One everyday casualty of this phenomena is the policy of health care payers to only provide reimbursement for treatments that are approved by the FDA. In fact, when a drug is under development by a pharmaceutical company, it must be registered for clinical studies for a specific FDA-approved diagnosis. As DSM has evolved from DSM I through our newest DSM-5-TR, many diagnoses have surfaced and disappeared as the nosology evolves. Two examples of diagnoses that have come and gone—hence there are drugs with FDA approval for a diagnosis that no longer exists—include symptomatic relief of anxiety and tension associated with psychoneurosis and bipolar I disorder, most recent episode mixed. On the other hand, a diagnosis that was new to DSM-5, disruptive mood dysregulation disorder, has no FDA-approved drug.

More significantly, most of the diagnoses across all of the DSMs have no FDA-approved drug. A classic article that I often reference, “An Analysis of the High Psychotropic Off-Label Use in Psychiatric Disorders: The Majority of Psychiatric Diagnoses Have No Approved Drugs,” concluded that only 11.8% of DSM-IV-TR diagnoses have an FDA-approved drug.

With the publication of DSM-5 in 2013, this percentage has likely decreased.

Once again it is time to embrace a new DSM, with the likely accompaniment of burdensome medical record modifications and coding challenges with health care payers. To speak honestly, DSM-5 was a major disappointment for me. It would have been a win for our field if DSM-5-TR had at the very least brought back the 5 axes diagnostic summary, which informed a comprehensive treatment plan. It is 72 years after the publication of DSM-I in 1952, and maybe we should consider ending the DSM era and start from scratch by creating a diagnostic and treatment manual that mirrors the extensive and diverse knowledge base that has continued to accrue.

 is medical director, Brain Health, Exeter, New Hampshire; Editor in Chief, 

An analysis of the high psychotropic off-label use in psychiatric disorders: the majority of psychiatric diagnoses have no approved drugs

Once again it is time to embrace a new DSM. What can we expect from this new version?

DSM-5-TR…Already?

John J. Miller, MD, shares history of the DSM. What knowledge from previous iterations and what new additions in this iteration can be useful in diagnosing? 

John J. Miller, MD

Articles

A Dangerous Evolution?

Learn With Us in San Diego

Movements in the 4th Dimension

Patient Discussion and the Importance of Continuous Patient Education

DSM-5-TR…Already?

The Next Iteration of DSM