Correcting Psychiatry’s False Assumptions and Implementing Parity

May 27, 2015

It is a source of shame for our nation that for most Americans in need-especially those with serious mental illness-the mental health system is dysfunctional. Nevertheless, we can fix some of the ways the system is broken.

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It is a source of shame for our nation that for most Americans in need-especially those with serious mental illness-the mental health system is dysfunctional. Provision of population mental health services is a complex systems issue that requires multiple stakeholders to work in partnership to improve it. Federal and state governments (as funders of both care and research), clinicians, hospitals, accountable care organizations, and insurers, as well as patients and families, are key stakeholders. Only the federal government has authority to convene all of the former, but Washington’s current dysfunction makes this unlikely. Nevertheless, we can fix some of the ways the system is broken. I will focus here on 2 critical areas-the paradigm of clinical care and implementation of parity.

Psychiatry’s false assumptions

Psychiatry clings to 3 false assumptions despite evidence to the contrary, and psychiatrists, our patients and their families, and our nation pay a price as a result. The assumptions are that:

• Genes = disease

• Patients present with single disorders that respond to single evidence-based treatments

• The best treatments are pills

Genes = disease

Mental disorders are clearly heritable. Molecular genetic research teaches us that there are 2 kinds of genes-those that make proteins and those that regulate other genes, often in response to the environment. We hoped that sequencing the human genome would lead to identification of the genetic underpinnings of mental disorders, but genes turn out to be rough plans rather than detailed blueprints for an individual.

Over 125 relevant genetic loci have been identified in schizophrenia, which indicates that heritability of this and other psychotic disorders is far more complex and multifactorial than we expected. Single nucleotide polymorphisms (SNPs) are associated with some cancers, type 2 diabetes mellitus, and inflammatory bowel disease. Genome-wide association studies of depression were unable to find meaningful SNPs that illuminate genetic underpinnings of this common disorder.1 No biomarkers for depression have been found, and the search for them has been likened to that for the Holy Grail.

Meanwhile, Tully and colleagues2 offer us a glimpse of the importance of environmental factors in depression by demonstrating that mothers who are depressed during childrearing often have depressed adolescents-whether their children share their genes or are adopted. Other studies of early adversity demonstrate that it is a veritable “enviro-marker,” associated with a high risk of mental illness, substance use, and medical disorders-not just with PTSD.3

Emerging evidence shows us that disease is not simply encoded in genes, but that gene-by-environment interactions (“epigenetics”) are central in understanding disorders. Yet as a profession, psychiatry has shifted toward what former APA president Steve Sharfstein called in his presidential address the “bio-bio-bio” model. Many in psychiatry have moved away from and sometimes deride the biopsychosocial model. Ironically, this has happened as the above evidence from genetics has cautioned us to take environmental factors more seriously. Numerous studies demonstrate the effectiveness of psychodynamic psychotherapy and CBT for multiple individual and complex comorbid disorders-with the ability to distinguish therapy responders from non-responders on imaging.4

The assumption that disease is all about genes and biology does help reduce blame and stigma. Nevertheless, the assumption doesn’t fit the evolving data, and clinging to it risks crippling our ability to understand and treat our patients’ problems in nuanced and sophisticated ways that attend to biological and environmental factors in a “both/and” rather than “either/or” model. After all, another way to say “epigenetics” or “gene-by-environment interactions” is “biopsychosocial.”

Patients present with single disorders that respond to single evidence-based treatments

Our practice guidelines and our randomized trials assume that most patients have single disorders that respond to evidence-based treatments in carefully selected non-comorbid patient samples. Yet, clinicians know from practice-based evidence what the research evidence shows: most patients have multiple comorbid disorders and failure rates for our best treatments are high.

For example, in depression, 78% of patients in the large STAR*D sample presented with comorbidity or suicidal ideation that would have excluded them from randomized trials; however, these comorbid patients had lower response to treatment and lower remission rates.5 So if you feel, as many clinicians do, that the patients you work with are sicker than those a drug was tested on, you are right about 4 times out of 5.

Again using depression as an example, we are learning how important comorbid personality disorders are to treatment outcome-especially comorbid borderline personality disorder (BPD). The large, multisite Collaborative Longitudinal Personality Disorders Study (CLPS) concluded that the presence of personality disorders, especially BPD, “robustly predicted persistence” of MDD, suggesting diagnosis and treatment of personality disorders are essential in treating depression lest it become treatment-resistant.6

However, in our focus on the medical model, personality disorders are underdiagnosed. In DSM-IV, the most frequent Axis II diagnosis made was “deferred,” and there is no reason to think this will change with DSM-5. Biological tunnel vision can lead to missing the reality of clinical complexity and interfere with provision of optimal patient care.

The best treatments are pills

We have overestimated the efficacy of antidepressants by about a third when all studies are considered, and 75% of antidepressant effect is placebo effect.7,8 The CATIE schizophrenia study showed that patients don’t find that the benefits of our pills outweigh the adverse effects.9 Our pills work, but not as well as we might hope, while the effect sizes of psychotherapy studies are actually larger than those for medications.10 In some disorders, the combination of psychotherapy and medications is superior to medications alone, and when early adversity includes sexual abuse, medications may add little to the outcomes achieved with psychotherapy alone.11

Psychiatry has reified skills in diagnosis and prescribing medications as defining characteristics. If we take seriously the message that genes and environment matter in the causation and treatment of disorders, we will need to focus much more on training in and the practice of psychosocial treatment in psychiatry-or surrender our role as the most sophisticated mental health clinicians. You can’t practice what you aren’t taught-and can’t teach what you never learned. However, currently the only place within the APA that stands for the importance of psychosocial factors in the causation and treatment of mental disorders is the unfunded APA Psychotherapy Caucus. The Caucus originated in 2014 as a grassroots effort by a dozen APA members concerned that the APA leadership saw no reason to establish or fund such a group within its Components. The Caucus has grown from 12 founding members in early 2014 to over 200. All interested psychiatrists are invited to join by contacting me at Eric.Plakun@austenriggs.net.

Psychiatry would be well advised to rethink its identity and to reaffirm the biopsychosocial paradigm to improve patient care. Attending to the importance of psychosocial or environmental factors also means taking more seriously the contributions of psychoanalytic theory, which has studied environmental influences for over a hundred years and, as Nobel laureate neurobiologist Eric Kandel12 stated, offers the most nuanced and sophisticated model of the mind that we have.

Psychodynamic psychiatry, which is the intersection between general psychiatry and psychoanalytic theory, deserves renewed attention as part of fixing a broken system. This does not mean offering individual psychoanalysis to more patients, but it does mean including psychoanalytic perspectives in our work with patients. This can occur through the practice of “psychodynamic psychopharmacology” that attends to the meaning effects as well as the neurochemical effects of medications, through knowledge of individual and group dynamics and defense mechanisms to help psychiatrists be better therapists and better treatment team leaders, and through faithful attention to the authority, agency, and competent voice of the patient in negotiating an alliance and in treatment.13

Psychoanalysis is not the only psychosocial treatment worth our attention. CBT, DBT, and other behavioral therapies, as well as group and family therapy, have much to offer. Attention to common factors shared by evidence-based behavioral and psychodynamic therapies offers hope of training those psychiatrists who will never master a manualized therapy to better treat difficult patients, such as suicidal patients with BPD.14,15

There are more issues that must remain unaddressed here, such as future directions in diagnosis and why the NIMH spends the vast bulk of its research dollars studying brain function rather than common factors across psychosocial treatments that could directly improve patient outcomes.

Full implementation of parity

Mental health care is approved and funded in a managed care model. Managed care operates with the same moral imperative as the environmental movement-focused on preserving limited resources. But US managed care companies usually function as revenue-driven deniers of care, especially in mental health. A recent study published in JAMA Psychiatry revealed that only 55% of psychiatrists accepted insurance in 2009-2010 compared with 88.7% of physicians in other medical specialties.16 The data further revealed significantly lower Medicare and Medicaid acceptance rates among psychiatrists than physicians in other medical specialties. Low rates of reimbursement for mental health services; quantitative limits, such as annual limits on numbers of sessions or dollars available for care; and non-quantitative limits, such as utilization review hurdles for prior authorization account for much “opting out” of the system of care.

Though understandable given the context, these high “opt out” rates are a national embarrassment. The Mental Health Parity and Addiction Equity Act (MHPAEA, or parity law) offers hope of a remedy, since it forbids quantitative or non-quantitative mental health care limits more restrictive than those in medical and surgical care. For persons with diabetes mellitus, arbitrary annual limits in the number of office visits or dollar limits for services would be unthinkable, but such limits are of-ten imposed for people with mental disorders.

Similarly, the managed care stance that patients with mental disorders should be treated either as inpatients or outpatients, with no access to intermediate levels of care (such as residential treatment), seems inconsistent with parity legislation. Would a man with a stroke be told that once he was no longer in need of acute inpatient treatment, he had to return to outpatient treatment, with no access to intermediate levels of care to begin to learn to speak, walk, and resume self-care?

Despite parity legislation, many insurance companies continue to deny access to care based on such arbitrary exclusions. Successful legal challenges can establish case law fully implementing mental health parity. The good news is that such lawsuits, some as class actions, are under way and are gaining traction.

In December 2014, the CBS show 60 Minutes devoted part of an episode to a lawsuit (Wit et al v United Behavioral Health) about arbitrary denial of residential treatment to patients with complex comorbid mood, eating, and substance use disorders. The segment made clear the devastating consequences to seriously ill patients of a pattern of reflexive denial of care by managed care reviewers. In another class action suit (Craft et al v Health Care Service Corporation) in March 2015, the judge ruled against the insurance company’s motion to dismiss, which claimed the lawsuit lacked merit because the insurance contract specifically excluded residential care. The ruling is promising to the plaintiffs because it suggests the judge sees exclusion of residential treatment as a non-quantitative limit prohibited by parity. Other cases hold managed care organizations accountable for other quantitative and non-quantitative limits on care. Their outcomes have the potential to force reform of egregious managed care practices that are part of what is broken in our mental health system.

Together our voices matter. Please consider joining “Biopsychosocial Matters,” for discussion of issues such as these at www.meaningmatterscommunity.org.

Disclosures:

Dr Plakun is Associate Medical Director of and Director of Admissions at the Austen Riggs Center in Stockbridge, Mass. He was a Harvard Medical School clinical faculty member for over 20 years. Editor of two books, including Treatment Resistance and Patient Authority: The Austen Riggs Reader (WW Norton & Company, 2011), and author of over 40 published papers and book chapters, he has presented widely in the US and overseas. Dr Plakun is a Distinguished Life Fellow of the American Psychiatric Association, Past Chair of its Committee on Psychotherapy by Psychiatrists, and founding leader of its Psychotherapy Caucus. He is a past member of the APA Assembly Executive Committee, and Past Chair of the Assembly Task Force on Psychotherapy by Psychiatrists. Dr Plakun is a Psychoanalytic Fellow of the American Academy of Psychoanalysis and Dynamic Psychiatry and a Fellow of the American College of Psychoanalysts and the American College of Psychiatrists. He has been honored as the Outstanding Psychiatrist in Clinical Psychiatry by the Massachusetts Psychiatric Society.

References:

1. Hek K, Demirkan A, Lahti J, et al. A genome-wide association study of depressive symptoms. Biol Psychiatry. 2013;73:667-678.

2. Tully EC, Iacono WG, McGue M. An adoption study of parental depression as an environmental liability for adolescent depression and childhood disruptive disorders. Am J Psychiatry. 2008;165:1148-1154.

3. Molnar BE, Buka SL, Kessler RC. Child sexual abuse and subsequent psychopathology: results from the National Comorbidity Survey. Am J Public Health. 2001;91:753-760.

4. Lazar SG. Psychotherapy Is Worth It: A Comprehensive Review of Its Cost-Effectiveness. Washington, DC: American Psychiatric Publishing, Inc, 2010.

5. Wisniewski SR, Rush AJ, Nierenberg AA, et al. Can phase III trial results of antidepressant medications be generalized to clinical practice? A STAR*D report. Am J Psychiatry. 2009;166:599-607.

6. Skodol AE, Grilo CM, Keyes KM, et al. Relationship of personality disorders to the course of major depressive disorder in a nationally representative sample. Am J Psychiatry. 2011;168:257-264.

7. Turner EH, Matthews AM, Linardatos E, et al. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med. 2008;358:252-260.

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9. Lieberman JA, Stroup TS, McEvoy JP, et al; Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Investigators. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia [published correction appears in N Engl J Med. 2010;363:1092-1093]. N Engl J Med. 2005;353: 1209-1223.

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12. Kandel E. Paper presented at: Meeting of the American Psychoanalytic Association; January 2011; New York.

13. Plakun EM, ed. Treatment Resistance and Patient Authority: The Austen Riggs Reader. New York: WW Norton & Company; 2011.

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15. Sledge W, Plakun EM, Bauer S, et al; Group for the Advancement of Psychiatry Psychotherapy Committee. Psychotherapy for suicidal patients with borderline personality disorder: an expert consensus review of common factors across five therapies. Borderline Personality Disorder and Emotion Dysregulation. 2014;1:16. http://www.bpded.com/ content/1/1/16. Accessed April 16, 2015.

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