Synapse On-Line
THE WEST HUDSON PSYCHIATRIC SOCIETY VIRTUAL NEWSLETTER
Published bimonthly in conjunction with the printed newsletter
January-February 1997 Edition
Robert N. Sobel, M.D., Editor & Syed Abdullah, M.D., Co-Editor
Leslie Citrome, M.D., M.P.H., Virtual Editor
CONTENTS
The President's Desk
Between Psychiatry and the Law - Psychiatry and the Death Penalty, Part 2
The Edifice Complex - A New Syndrome
Clinical Practice Protocols
Public Affairs
Private Practice - Depression Screening
The President's Desk
Capitalism, the twin-edged sword, seems to be the best "human contract" as proven in the naturalistic lab of planet earth. The regulated economy under communism failed to bring about a functioning, enduring society-a conclusion we can draw as we observed the collapse of the Soviet Union. However, the MBA mentality that has pervaded American life seems perverse. Though we lack a planned society, the reactive-rather than proactive-approach we have taken towards the health care revolution surely must give us pause. Governor Pataki of New York has signed into law one of the most comprehensive pieces of managed care legislation in the country, The Health Care Bill of Rights. The law goes into effect on January 1 1997 (with other sections going into effect on April 1, 1997) and includes provisions for disclosure of contract details to consumers, due process protections for physicians, strengthening of utilization review procedures and requirements that networks have enough providers to allow patients a choice of physicians. I guess we can take comfort in the notion, "better late than never." I need not enumerate the harm and profiteering that has taken place in the interim. Nor do I need to point out that the legal profession probably benefits from this legislation which will ultimately require challenges in court to ensure that the corporate health care magnates live up to the spirit of the law.
Those who read the tea leaves and predicted that managed care as it first emerged was only a transitional mode and would ultimately lead to capitation can revel in the fact they were right. In a November 25, 1996 front page story in the New York Times, entitled "Reduced HMO Fees Cause Concern About Patient Care," notes that the rapid reduction of fees by HMO's is being replaced by fixed monthly fees per patient. This is reported to be relatively new to the New York region but in California, 60% of HMO contracts are fixed fee. This is the other edge of the sword of capitalism. Medicine has been coerced into changing from an individual contract between physician and patient into a functional employee of a corporation where MBA, bottom line mentality reins supreme. The capitated approach to health care creates an overt and covert incentive to treat minimally and to avoid seriously ill patients and the elderly. Studies have shown that the last two years of an individual's life consume about 90% of their lifetime health costs. Is this the society we want to become?
To belabor my point, I will close with a quote from the November 11, 1996 issue of Fortune which demonstrates America's new-think, i.e., the only value scale we measure by is the bottom line. "Data for the 12 states show plainly that lower levels of imprisonment mean higher levels of crime. Levitt writes: "In the three years following the court's handing down a final decision, prison populations are estimated to grow a total of 13.7% to 19.7% more slowly than if there had been no litigation, while violent crime rates are 7.9% to 8.3% higher, and property crime rates are 5.7% to 6.2% higher." The typical guy in prison has committed 15 serious crimes a year. Putting away 1,000 extra bad guys for a year reduces the expected number of murders by four, rapes by 53, assaults by 1,200, robberies by 1,100, burglaries by 2,600, auto thefts by 700, and other larcenies by 9,200.
The economics of putting people away are attractive. Incarceration costs around $33,000 a year, while estimates of the monetary and quality-of-life costs of crime-admittedly tougher to calculate-average around $60,000. We need more prisoners. How many more? Levitt's article does not squarely address this question, but his calculations indicate that we could raise the prison population to 1,350,000 before we would be putting away people whose crimes cost less than their incarceration. The figure implies that we need a 23% boost in prisoner totals. To be sure, no such precision is really possible, given the inescapable wobbliness of the quality-of-life cost estimates. There is, however, no doubt that some increase is needed-maybe more than 23%, maybe less. Either way, your sister will be safer.
Robert N. Sobel, M.D.
Between Psychiatry and the Law Psychiatry and the Death Penalty, Part 2
Continuing our discussion of psychiatric participation in capitol sentencing cases, I thought it would be important to describe what we know about current death row inmates; their psychiatric, neurologic and psychoeducational characteristics. As I will describe, these are seriously troubled people (prior to entering death row) and yet, they still were given death sentences. It is strange that their serious problems were not determined prior to trial, and utilized to mitigate the death penalty. It may well be (as the research seems to show) that these are people who attempt to minimize their psychiatric problems and who are too impaired to effectively help their attorneys (who themselves may be overwhelmed by cases and/or not adequately trained to pick up these disabilities themselves) mount an adequate mitigation defense.
Dorothy Otnow Lewis, at NYU Medical School, has done much of the research on death row inmates, both adults and juveniles. At present, there are approximately 20,000 arrests for murder each year, and about 250 (about 1%) are sentenced to death. Currently, about 1500 inmates are on death row across the country. About 40 have been put to death since the door was reopened, allowing death penalties to go forward. Obviously, a minute number are actually put to death. This may be an indication of the extent of the mental impairment in murderers, (leading to most being sentenced to life in prison) or the ambivalence of the judicial system about this penalty (the only one in the western world).
Most interesting about death row inmates, is the extremely high incidence of serious psychiatric, neurologic and psychoeducational deficits. In Dr. Lewis' study of 15 adult consecutive death row inmates in 1984 (sentenced between 1976 and 1984): a) All had histories of head injuries objectively determined, and nearly all had evidence of neurological dysfunction. Five had major neurological impairments, including seizures, paralysis, brain atrophy, psychomotor epilepsy and other neurologic signs. b) On psychological testing, ten had evidence of significant cognitive dysfunction. c) Nine had serious psychiatric symptoms in childhood, four had tried suicide, six were found to be chronically psychotic, antedating incarceration; another three were periodically psychotic and two had bipolar disorder.
Yet, none appeared to be floridly psychotic at first glance and nearly all attempted to minimize their problems. Since these disorders affect judgment, reality testing and self-control, they certainly are relevant to sentencing.
The other study. of 14 consecutive juveniles on death row, identified nearly all as having been severely physically and/or sexually abused. Nine had serious neurologic deficits, seven were psychotic, and the other seven had serious psychiatric symptoms. Only two had IQ's above 90 and ten had significant impairments on psycho-educational testing. Nearly all had parents with alcohol, drug and psychiatric histories.
Although there are no studies which clearly link past deficits with future violent behavior, and we well know that many people with these deficits never commit crimes, the statute does allow for mitigation of the death penalty when these deficits are present and are not overshadowed by aggravating factors.
In the next article, I will discuss another mitigating factor, Mental Retardation and the functional link between neuropsychological deficits and instant offense behavior.
Alan J. Tuckman, M.D Chairman, Ethics Committee
The Edifice Complex - A New Syndrome
Ever since the construction of the Chrysler Building and the Empire State Building, America has not been the same. The country went into a frenzy of building skyscrapers from coast to coast. The Sears Tower in Chicago and the World Trade Center s Twin Towers are standing testimony to this obsession with building higher and bigger high risers as a hallmark of a great nation, a prosperous country. Naturally, this preoccupation has been specially marked in New York State where, despite ecological and environmental constraints, there are so many towers and skyscrapers and more are planned by entrepreneurs like Donald Trump and others.
The State of New York, and specially its Office of Mental Health, also has a love affair with all that goes skyward. We have witnessed in this decade the building of several architectural behemoths in the form of two brand new buildings for the New York State Psychiatric Institute in New York City. These new structures will have, it is said, more space and modern facilities, than the buildings that house the prestigious National Institute of Mental Health. Only about 18 miles to the north of the New State York Psychiatric Institute, another colossal complex of buildings is being built on the campus of Rockland Psychiatric Center! These will house the existing facilities of Nathan Kline Research Institute the existence of which is called to question every year at the State Budget time. The staff and research personnel are downsized routinely, while the facilities to house the state of art high tech equipment are being extended at a frantic pace.
On the Rockland Psychiatric Center campus we have witnessed another evidence of the Edifice Complex in the form of a multi million dollar reconstruction of mid-rise buildings just at a time when the State is poised to hand over the care of the mentally ill to managed care enterprises! Here again, every year there are staff cuts and downsizing of services but the Palace building continues unabated. A walk through the halls of these new buildings would give the naive visitor the impression that the State is really committed to the care of its mentally ill disenfranchised citizens. The reality, however, is that the State is turning away from the psychiatric care of a large section of the population - the elderly. Have you lately tried to get a person 65+ years old and in need of in- patient care, into a State facility like RPC? If you have, you must have found that the doors of these fine buildings are shut for services to such individuals!
And yet, these buildings were built with an eye for the provision of the most excellent psychiatric service to, among others, the senior citizens of the state. You must be wondering as to what happened to all the 65 year olds, and older patients that were traditionally cared for at Rockland Psychiatric Center? Well, under an executive mandate, they have been ordered to be placed in nursing homes run by private agencies. As if in anticipation of this development, nursing homes have mushroomed all over the metropolitan area to house these bewildered elderlies with or without their consent. An executive order does it, even over the objections of families. This is happening at a time when the strict standards imposed on private nursing homes are being eased by pending legislation.
A neurosis has been defined as a maladaptive and ineffective way of dealing with an internal conflict. Building palatial facilities and reducing real services, in response to the unmet needs of the mentally ill, is one wasteful way of dissipating the meager resources at hand. It therefore, in my humble opinion, qualifies to become a new syndrome: The Edifice Complex.
Syed Abdullah, M.D.
Clinical Practice Protocols
Adapted from "Practice Protocols, Practice Parameters, Clinical Pathways, and Clinical Practice Guidelines: A Review" scheduled for publication in Administration and Policy in Mental Health, Spring 1997.
Clinical practice protocols and utilization guidelines have evolved with the advent of new reimbursement mechanisms for medical care. As the penetration of managed care in the health care market increases, practice protocols have the potential to shape the provision of care in a way unheard of a decade ago. Physician activism in formulating clinical practice guidelines holds forth the potential for significant input into this process.
The development of clinical practice guidelines has spread from utilization re-view agencies to physician specialty societies, federal agencies, managed care organizations, and academic health centers. Approximately 1,800 medical practice guidelines have been catalogued. Clinical guidelines differ from medical review criteria in that practice guidelines focus on assisting providers and patients in making decisions, whereas medical review criteria emphasize the evaluation of healthcare decisions and outcomes. Practice guidelines are also sometimes referred to as practice protocols, practice parameters, and clinical pathways.
Physicians have concerns with the basic concept of practice guidelines, including the possible emergence of "cookbook" medicine, the effect of patient variability, the need to keep guidelines current, and medicolegal issues about meeting the newly defined "standard of care". The medicolegal issue is especially relevant when a practice guideline or criteria is based on the desire for cost-containment. A physician must act in accordance with his/her duty of care, i.e., accepted medical standards, in responding to utilization review decisions. Third party payers can also be held accountable when medically inappropriate decisions result from defects in designs or implementation of cost containment mechanisms.
A Tale of Two Guidelines: In April 1993, the American Psychiatric Association (APA) published a practice guideline for Major Depressive Disorder in Adults. It appeared as a 26 page supplement to the American Journal of Psychiatry and was distributed to all psychiatrists belonging to the APA. Extra copies were available for sale at $22.50 each. Six psychiatrists served on the work group. One hundred and forty-two reviewers and consultants were acknowledged (read like a Who’s Who of American Psychiatry and all but four were MDs), and 36 organizations submitted comments (most organizations were from within the discipline of Psychiatry). One hundred and sixty-nine references were supplied. Out of the 21 pages devoted to text (minus acknowledgments and references), three pages were devoted to psychotherapy, three to medication treatment, two-thirds of a page to electroconvulsive therapy, and two pages to the issues of continuing treatment, maintenance treatment, and treatment resistance. Conclusions included that effective treatments for major depression include psychotherapy, antidepressant medication and electroconvulsive therapy, and that most patients are best treated with antidepressant medication coupled with psychotherapy. In addition, some patients with mild to moderate degrees of impairment may be treated with psychotherapy alone. There was some concern that the guidelines would become the gold standard by which psychiatric treatment for depression is judged, but the work group, in defending the guidelines, emphasized that it was not meant to serve as the final word.
In April 1993, the Agency for Health Care Policy and Research (AHCPR), a component of the Public Health Service of the U.S. Department of Health and Human Services, issued a clinical practice guideline entitled Depression in Primary Care. It spanned two volumes, with 124 pages devoted to detection and diagnosis, and 175 pages on treatment of major depression. A 33 page pamphlet served as a patients guide. A 21 page booklet served as a quick reference guide for clinicians. The materials were free and available in quantity from the AHCPR Publications Clearinghouse. The depression guideline panel was composed of eleven experts from diverse disciplines (psychiatry, internal medicine, social work, family medicine, psychology, and nursing), as well as a consumer representative. Three of the panel, including its chair, were also on the list of reviewers and consultants for the guidelines promulgated by the APA. Over 100 persons were also acknowledged as reviewing consultants, scientific reviewers, those providing peer and pilot review, and those providing additional scientific, technical and administrative support. Three patient advocacy groups and 73 professional organizations provided input. Over 500 references were supplied. The guideline was developed to assist patients and primary care practitioners in the detection and diagnosis of depressive conditions and the treatment of major depressive disorder. The guideline is an abbreviated version of the 1,200 page Depression Guideline Report, containing over 3,500 references.
The volume on treatment contains 28 pages on acute management with medication, 16 pages on acute management with psychotherapy, and 7 pages on using both psychotherapy and medication in the acute phase. In a synopsis of the report, it was noted that depression can almost always be treated successfully, either with medication, psychotherapy, or a combination of both, but that combined therapy should not routinely be the first treatment for all depressed patients. This is in contrast to the APA guidelines which places a heavier emphasis on the importance of psychotherapy, and the idea that combination therapy may be better than either modality (medication or psychotherapy) alone. The target audience of the guidelines is different: the APA is aiming at psychiatrists, the AHCPR at primary care providers. The amount of material produced by the AHCPR dwarfs the report of the APA, and is reflective of the different missions of the different organizations, as well as their funding.
In contrast to the guidelines developed by the APA, managed care organizations may utilize criteria that are kept secret, allowing for the possibility of criteria being arbitrarily changed on the basis of revenues and expenses. There is a heavy emphasis on the evaluation of functional impairment in the assessment of what is medically necessary (and reimbursable). Managed care companies are also utilizing behavioral outcomes and rating providers (provider profiling). For these companies cost is a major issue and new information about cost and outcomes may force more discussion about this topic in future revisions of the APA depression guidelines.
Leslie Citrome, M.D., M.P.H.
Public Affairs
This month was very busy for Public Affairs! First. I want to thank Dr. David Brody who spoke at Beth Am Temple on October 11th, in honor of Mental Illness Awareness Week. He spoke about guilt and depression. He was inspiring and many members of the congregation thanked us for educating them about mental illness and how it is an illness that is readily treatable.
I would also like to thank Dr. Marc Tarle who spoke at Barnes & Noble. This was another great community service that helped to destigmatize mental illness and give the public a positive image of the psychiatrist profession.
The Mental Health Coalition of Rockland County was presented a proclamation by Scott Vanderhoff during the week of Mental Illness Awareness Week. The proclamation stressed the importance of recognizing and treating mental illness. During the Mental Illness Awareness Week, Carol Olan, C.S.W. and I attended a FAMI-AMI conference in New York City. The speakers honored Dr. Kay Redford Jamison, Ph.D., for her leadership role in the field of mental health. Dr. Jamison is a professor of psychiatry at John Hopkins University. She recently has spoken to the public about her own history of bipolar disorder. She has written the book, "The Unquiet Mind". Mike Wallace, from the television show "60 Minutes", was also a speaker at the FAMI-AMI conference. He spoke about his own history of depression. It was quite an inspiration to hear these celebrities speak so openly about their own struggles with their illnesses. We invited both Dr. Jamison and Mike Wallace to come to Rockland County next year to speak to us!!! We're hoping to get a positive response.
The Depression Screening at Nanuet Mall on October 10th was a success! Many thanks to all of you who participated. Once again this is a great community service and special way of reaching out to people of Rockland County and destigmatizing mental illness. A special thanks to Jim Flax and Les Citrome for their special efforts in coordinating the event.
Some upcoming events include speakers at the Rotary Club and at Rockland Community College. The Mental Health Coalition will be having programs at Stony Point Elementary School and Rockland Community College this spring. Anyone interested in helping out please contact me: Dr. Kroplick at 914-364-2428. Once again, thanks to all of you who have been active and supportive and have helped to strengthen our role as leaders in our community.
Lois Kroplick, D.O.
Private Practice - Depression Screening
The Private Practice Committee sponsored its' sixth "Depression Screening" at the Nanuet Mall on Thursday, October 10 as part of National Mental Illness Awareness Week. Two to four psychiatrists were in the second level Community Service Booth from 9:30 AM to 7:30 PM to talk with passersby, answer questions, distribute literature, hand out our private practice referral guide, and conduct individual depression screenings for those who wished it. It was once again a resounding success!
The shoppers passing by saw hundreds of individuals openly talking with us about mental illness in a setting designed to eliminate stigma and fear. Seventy-five individuals took the Zung Depression Screening. Forty-three scored at or above the minimal to mild depression category and were urged to seek psychiatric consultation. This number is fewer than those who have participated in our previous depression screenings but continues to be an enormous number of people, averaging more than any other site. Those of us who participated were again very pleasantly surprised by the openness of the passersby who spoke with us in the public setting of the mall. Your colleagues who volunteered reiterated the refreshing change this professional activity is from the usual clinical settings in which we all work.
I wish to thank all of the participants including Drs. Syed Abdullah, Nigel Bark, Mark Bernstein, Joan Berson, Dave Brody, Les Citrome, Dinkar Desai, Paul Ducker, Aristide Esser, Jane Kelman, Lois Kroplick, Scott Lawrence, Lawrence Levitt, Narendra Patel, and Denny Walters. I invite these individuals and others to volunteer for next years' Depression Screening in October, 1997. It is a rewarding experience and additionally a chance to talk during free time with your colleagues manning the booth with you.
Dista again provided substantial financial and logistical support for this event for which we are grateful.
James W. Flax, M.D., M.P.H., Public Affairs Committee