Human Rights and Managed Care: Part 2

Steven Moffic, M.D.

May 17, 2012

Let me state from the outset that I didn’t suggest presenting on this topic. In fact, I was rather taken aback when Dr. Pumariega, the upcoming President of the American Association for Social Psychiatry, asked me to do so. After all, I thought I had written and presented about most every ethical aspect of managed care over the last 20 years, and was getting tired about being a lightning rod for all the emotional storms around this process. For almost a decade, I had left the belly of this beast, at least as far as administrative responsibility. But, somehow, the connection of human rights and managed care never came to mind.

Or, did I just repress that? Fairly quickly after this invitation, an intrusive memory flashed back into my mind. Back in 1990 or so, I had started a new job in Milwaukee, where I was directing a new academic not-for-profit managed care system, perhaps the first in the nation. This was around the same time that psychopharmacology was to take off. Not until much later did it become apparent how much managed care companies emphasized medication over psychotherapy and changed what most psychiatrists did.

For my very first presentation as part of a Wisconsin Psychiatric Association meeting, which actually was a debate on managed mental healthcare, my opponent compared managed care to Nazism. How dare he, I reacted at that time?! I am Jewish, and my whole extended family in Europe, other than my grandparents who left early enough, was apparently killed by the Nazis. This seemed to be a cheap shot at the time. Or, was it? And, how could doctors in managed care systems be equated in any way with the Nazi doctors that the renowned psychiatrist Robert Jay Lifton had interviewed and researched.

Then, another intrusive associative flashback occurred, to a former President of the American Psychiatric Association, Harold Eist, M.D., who deemed managed care to be “evil” and suggested in public that I was evil for being involved with it as a medical director. For that, I responded that I was involved as a participant/observer in order to try to understand the ethical aspects and challenges of managed care, and that our academic “company” was not-for-profit. Actually, to my wife’s chagrin, I was offered a significant percentage of any savings we achieved through our contracts, but I turned that down for professional ethical reasons.

OK, now I was wondering and worried. Maybe I was suffering from Post Managed Care Stress Disorder, and these memories were being triggered by this planned symposium. So, if I was not to intermittently suffer incessantly, maybe I needed to reassess if there was something to this linkage.

Then again, I had tried to be as fair as I could when I wrote the book from my experience in 1997, called “The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare”, which, for better or worse, got an unprecedented re-review in the January, 2010 journal, Psychiatric Services. However, there was nary a mention of human rights in the book, or in any of the reviews, then and now. I also didn’t mention any possible connection to Nazis and totalitarianism, though Dr. Lifton’s concept of “doubling” could fit, not only the harmful work of Nazi doctors, but the denials of managed care medical directors, who otherwise might seem like nice and compassionate people. In fact, many of the early medical directors in managed care came out of community psychiatry. One can extend this process to the frightening possibility that we all are vulnerable to “doubling” under the right social circumstances.

Now, after leaving managed care administration in 2003 and ending up in prison in 2009, and no, in case you are wondering, not in prison for being sentenced for something I did wrong in managed care. No, I ended up there as a part-time psychiatrist at a medium-security prison, somewhat like the one Madoff is in, curious to work in about the only mental healthcare system I had not led and/or worked in. There, I quickly became a bit more aware of human rights. Due to a federal lawsuit, prisoners became one of the few groups in the USA that had a human right to healthcare. We psychiatrists can have some pride that finally our APA Assembly recently passed an Action Paper declaring access to health care as a right.

Perhaps it was the impact of making mental healthcare in prison a human right that partially explained why I found out that I could provide better mental healthcare there than in my community mental health clinic outside of prison. I also knew that some prison systems, though not mine, were indeed run by private managed care companies. So, here was one unexpected connection between human rights and managed care. But this is the first situation that will indicate how complex this condition can be. Human rights for healthcare in prison is one thing; avoiding understaffing and overcrowding that limits security and the ability to provide enough healthcare is another. States can vary enormously in how they handle care, including mental healthcare, and security. Managed care companies would generally go only into the better funded prison systems.

Now, of course, having security as the first priority is reminiscent of many governments in history and in our time. It can also be reminiscent of the harsh and extreme mental health commitment laws of the past.

Poor or vindictive security in correctional settings per se can lead to interpersonal conflict, triggers to past trauma, abuse of the vulnerable, and solitary confinement, which can then lead to psychosis. This is often clearly a violation of our 8th Constitutional Amendment, Cruel & Unusual Punishment.

(To be continued in Part 3, which will turn to human rights after this initial discussion of my involvement in managed care)

Steven Moffic, M.D.

Sad in Psychiatry: Affectionately called a “gadfly,” and  known as “da man in psychiatric ethics,” Steven Moffic writes about what makes him sad about modern day psychiatry, and how to “treat” that condition so that we will become glad about what psychiatrists can do to help.

 

 

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54 thoughts on “Human Rights and Managed Care: Part 2

  1. “It can also be reminiscent of the harsh and extreme mental health commitment laws of the past.”

    You are claiming harsh psychiatric commitments are a thing “of the past”.

    This is false, and offensive.

  2. Thanks for catching that, “anonymous”. I actually agree with you. I had noted that in proof reading the blog, but decided to leave it as is. Certainly, in some states and situations, the commitment laws and proceedings are still abused, but from my vantage point (not yours, I know) it is overall much better. Many will say that nowadays the “side effect” of such changes in some places is that people die with their rights on.

    • I like the sound of dying with my rights on. I’d rather die than be owned like a slave by psychiatry.

      If you want to rescue people who haven’t asked for your help from ‘dying with their rights on’, you better be dead certain your system of forced intervention is not destroying other lives in the process. You can’t be certain can you? So why gamble with lives?

  3. But better is not the same as good.

    I did involuntary commitment work for a brief while and it was the worst job I ever had. Not because of the work – I was actually very skilled at delivering brief therapy in the ER and getting a lot of folks to be able to go home safely whom others would probably have committed, which was very rewarding. But the ones who were not able to be safe… well, let me just say that one trip to the psych ward convinced me that holding anyone there for “mental health” treatment was akin to a criminal act. It was a horrible ethical dilemma to have the choice between letting someone go home who plans to end their life and committing them to an institution that would make me think really seriously about ending mine if I had to go there. Restraints, forced drugs, screaming patients left unattended, and an atmosphere of tension and at times hostility (mostly emanating from the psychiatrists themselves) made the environment extremely unlikely to be therapeutic to anyone who even had to walk through the ward.

    This was in 1994. Not that long ago. Nothing I have seen suggests to me that this has changed substantially in most psych hospitals. I am sure I’d feel the same way if I were placed in the same job today. Holding someone in such a facility against their will for “stabilization” is brutal and traumatic for anyone.

    —- Steve

    • I can attest that the 21st century has brought no improvement in a vile practice that cannot be improved.

      How do you improve violently meddling in somebody’s life and completely having nothing but contempt for their express wishes?

      How can the domination, of one party by another be made ‘better’? It can’t.

      It always has been a vile and inhuman practice. It always will be until it is abolished and innocent people are let alone, and criminals go to prison.

  4. Some, or maybe a lot, of improvement since 1994. Restraints are not used at all in many hospital systems. Much more talking and human interaction, another “Steve”.

    And, thanks, Altostrata, for the clarification. Way too much personal blame for what not caused by someone; like throwing the baby out with the dirty bathwater.

    • Chemicals are used to restrain instead of physical restraints. How is this an improvement? Tranquilizing people instead of tying them up? That’s not much to be proud of.

      I never you said you caused psychiatric force. You have defended the practice though. I have a right to tell you how offensive I think that is.

    • There’s been no improvement since 1994. “Chemical restraints” are widely used, and are in fact physical restraints. No point in using cuffs or belts when you can drug patients to the point of death. I was hospitalized in 1993, and again in 2010. My 2010 experience was much, much worse which is really saying something. There was MUCH LESS talking and interaction, (almost no talking with the psychiatrists,) and MUCH MORE drugging, which resulted in much more physical suffering. My psychiatrist actually discharged me and billed for a discharge meeting without even seeing with me… one of his less harmful practices.

      • Forgot to add I have a hard time wondering how it’s helpful to declare we have a human right to access a system that couldn’t care less about our physical health or human rights…

        • Stacy,

          I agree.
          Chemicals have become the new restraints.
          In fact, chemical lobotomies.

          And they are just as harmful, physically and emotionally -

          http://www.madinamerica.com/2011/11/%ef%bb%bftimeline/

          Conventional psychiatry tried to convice the rest of us that they have an either/or call to make – prisons or psychiatric hospitals.

          Those are not their calls to make.
          Those need to be made in real courts (not mental health kangaroo variety courts).

          They try to convince us that things have gotten “somewhat better”… They have not.

          The real reforms that need to take place are ones in which they are not needed. Dorothy Dix and the Quakers had better success with “moral treatment”… Loren Mosher’s Soteria was done with folks who had no background in psychiatry/psychology, who simply treated those diagnosed with “schizophrenia” with decency and respect…. The work of Abram Hoffer, M.D. led to a 90 percent recovery rate with safe shelter, nutrition (orthomolecular variety) and empathy.

          Conventional psychiatrists could take place in the recovery movement, the revolution we are seeing take place, if they were to admit that what they have done/continue to do does not work… If they make amends for their past, and move forward for real reform.

          But they will not be the high-and-mighty medical doctors many would like to be; they will be seen as “equals” with social workers, counselors, and other non-medical professionals… and (heaven-forbid), they will be equals with those with lived experience – a concept that frightens the hell out of most of them… Especially, when they will have to admit they know little or nothing about psychiatric drug withdrawal, and have to become humble-enough to ask for resources in that area.

          Amends, first.
          Humility, second.
          Progress, third.

          I’m not sure conventional psychiatry is up to the task… There may be a few. We’ll see; but the recovery movement, the revolution continues in the meantime, without them.

          Duane

          Duane

          • Duane,

            I love what you’re saying here.

            At the APA protest David Oaks said that “We don’t reform–the current mental health system is built on reform. We want a revolution.” I agree, and you’re right that the revolution is happening now regardless of what happens in mainstream psychiatry.

            I’m committed to resisting the force, fraud and fear mongering of conventional psychiatry, but otherwise they seem increasingly irrelevant to me.

            Thanks for your comments.

  5. I understand and mostly agree with the anti-psychiatry vibe in these comments. But as someone who has worked in prison reform and read hundreds letters from prisoners requesting litigation assistance for prison abuses and denial of health care, including psychiatric health care, I have mixed feelings. We ask prisoners to undergo pretty horrifying conditions, like solitary confinement, constant violence, going weeks with a clogged toilet, unsanitary conditions, extreme heat/cold, among other things. Is there any wonder they want some kind of mental outlet?

    We call these drugs chemical restraints, but to many prisoners they might be an imperfect form of relief that keeps them going in hard to believe living conditions. I know I received many letters from prisoners desperately seeking restoration of their mental healthcare. Whatever you think about psychiatric meds in the outside world, keep in mind that the prison community is a different place altogether in a lot of ways. If we want to help prisoners with mental illness, reforming prisons is definitely the first step.

    • I absolutely agree reforming prison conditions is important and inmates deserve relief, but I don’t see how neuroleptics or “chemical restraints” would be appropriate for providing relief. Perhaps SSRIs or benzos… I guess reasonable doses of neuroleptics would be okay, as long as they weren’t actually being used as “chemical restraints,” which I’m sure also happens in prisons and juvenile detention.

      • I’d put SSRIs and benzos in the same undesirable category as neuroleptics. They are not more lightweight neuroactive drugs, they’re just not as quickly destructive to the body.

        • Right, I just thought of them as more likely to provide “relief.” They can also be dangerous. My experience with neuroleptics is that they just make you really, really miserable and sick.

    • “But as someone who has worked in prison reform and read hundreds letters from prisoners requesting litigation assistance for prison abuses and denial of health care, including psychiatric health care, I have mixed feelings.”

      They wrote you a letter REQUESTING psychiatry. Good. Key point here is they WANT psychiatry. People who have it forced on them DON’T. Big difference.

      Solitary confinement is used in psychiatry’s prisons aka mental hospitals too.

      If someone’s a lifer in prison and they want to numb themselves out with psych drugs who can blame them. Just don’t pretend it is qualitatively different than numbing him out on heroin. No real brain disease is being treated in either case.

      • Another obvious difference is that prisons have been charged and convicted of a crime!

        I still think that the use of psychiatric drugs for prisoners is a violation of the 8th amendment; and should not be used.. but there might be an argument for a prisoner who is violent.

        We have 1 percent of the population who have been diagnosed with “schizohrenia”, another 3-4% diagnosed with “bipolar disorder”… The VAST MAJORITY of these 12-15 million people have committed no crime! Their only “crime” is to have experienced “strong mood swings”, extreme states of consciousness”, “deep emotional distress”.

        Many have undergone trauma in their lives prior to being diagnosed, and additional trauma onced diagnosed, from a system that forces them to undergo ongoing trauma!

        Prisoners deserve humane treatment, without question. But non-prisoners do not deserve to be treated as prisoners in any shape, form or fashion!

        Duane

        Duane

  6. Thanks for all the comments, even going off managed care, though obviously I would disagree that managed care is not important for the future. Right now and for the foreseeable future, managed care will greatly effect what one can receive in both health and mental healthcare.

    As to the recovery revolution without psychiatry, I hope that is true, but I doubt it. All the rights movements in America that have succeeded, such as civil rights and gay rights, have been carried by those being treated so badly, but needed a coalition of supporters to succeed. There are psychiatrists who will join the cause if you let them and quit bashing us as a group. Maybe value that we see things that can complement what you see, even if it is different at times.

    Prison mental healthcare is both different and similar to that available outside (and there are many writings of mine one can check if you would like – one won a national healthcare journalism award). There is much tragedy – too much imprisonment for the wrong reasons. All the young Black American men of our time (I call aparttime). But for those who want it, often better treatment than outside. And, believe it or not, they get off psychiatric meds they have been on a long time, sometimes cold turkey, without hardly any withdrawal effects. I’ve come to think of that as sort of a reverse placebo effect; if they convince themselves they can get off the meds successfully, they push through in sort of a “macho” way. May write about this more later.

    • Many people, perhaps most, can quit psychiatric drugs with tolerable withdrawal symptoms. A minority of people, however, experience extensive neurological damage from too-fast tapers.

      I would not say success in cold turkey is due to the proper “macho” attitude. It’s the luck of the draw.

      A “macho” attitude, however, can contribute to denial of withdrawal symptoms.

      Conversely, neurological susceptibility rather than attitude determines the severity of withdrawal symptoms.

    • Dr. Moffic,

      I question your understanding of civil rights and gay rights history. The revolutionary leaders of those movements recognized that folks who experience oppression are the ones that deliberate and define and advance the agenda. There were many supports from outside of the most oppressed, but they knew that they were not themselves part of the movement, but stood and acted in solidarity with the movement. They did not add insight without being solicited, they did not presume more/different knowledge of someone else’s suffering, nor was much of the interventions of well-wishers actually helpful.

      Furthermore, in case you really haven’t noticed, the gay rights and civil rights movements have not succeeded. I think much their lack of transformative and reforming power came from the co-opting of their movements by “supporters” who instead of either truly joining the struggle by putting themselves at risk in confronting racism, sexism, and heterosexism in their communities or just getting out of the way, chose to place themselves as mediators and stakeholders who had such a poor understanding of oppressive systems that they only stifled potential progress. They helped make overt oppression more covert/discursive, more difficult to challenge, and then took energy from the movements away by checking out after only small or symbolic victories.

      I would also add that the medical establishment (supported by government and industry) and psychiatry have played detrimental roles (that have harmed more than any of the benefits of the positive actions) in the advancement of these movements. A rampart crusade against illicit drug use and criminalization of users without providing effective care to limit harms of addiction and promote recovery, and not supporting families/communities deeply affected by halted much of the development of civil rights in the 70s/80s. Instead of fighting greater systemic injustice, communities were forced to spend more time/energy/money caring for their own and dealing with associated problems, finding ways to make up income of folks imprisoned, and forced to increasingly rely on public assistance/systems that had been considered part of problem in the first place. During this time, Doctors/psychiatrists were busy making beginning the process of uniting with pharmaceutical companies to develop/market “legal” psychiatric drugs to profit from. Throughout this time, black people experiencing distress due to all sorts of social, economic, and political oppression were being diagnosed with mental illnesses at higher rates than white people, and being placed on the legal drugs. Many folks who may have benefited from effective support were rightfully wary of seeking help due to such evidence of racist practices, let alone a history of abuse and exploitation (drapetomania, Tuskegee, Henrietta Lacks, etc.).

      While the APA depathologized homosexuality in the early 70s due to the pressure of the excellent organizing and action by the Gay Liberation Front that exposed a weak, frightened, theoretically bankrupt APA, the post-WWII years until then saw medicine/psychiatry as the experts of sexuality and pathosexuality and framed discussions around queer folk as sick, evil, damaged, invalid, and untrustworthy. They isolated gay people from each other and themselves by making people think gay people were few and far between, deeply ill and predatory, and that interacting with them would lead to its own pathology. Their theories played into criminalization, discrimination, and moralizing that really ended and damaged many lives. Even after the kind of removal of homosexuality from the DSM (replaced by a similar diagnosis), many psychiatrists still worked from a pathological model of sexuality, exposing many who sought or were forced into assistance from medicine/psychiatry great damage. As the AIDS crisis grew in the 80s and the gay folks had to shift their priorities to staying alive, maintaining vision of a future, and maintaining a community that they fought hard to build, medicine and psychiatry were often agents for repression and oppression. It was the poorly conducted and disseminated medical research that led everyone to believe that AIDS was a syndrome of particular groups (white gay men, sex workers, hemophiliacs, injecting drug users, Haitians, etc.) not a manifestation of a compromised immune system caused by a virus that could only be transmitted in limited ways and could affect anyone. All of the moralizing and pathologizing of the previous decades by psychiatrists brought out increased anti-gay fervor and fear, making many people, even gay people, think that they themselves had somehow psychogenically made manifest an illness that proved their pathology. This made many non-gay people think they could not get sick (which was untrue and led to deadly delay in evidence-based prevention/risk reduction efforts), but it made it ok for everyone to place their blame/fear/hostility on gay people for the existence of a virus, excused great discrimination and invalidating, all during a time when so many were suffering tremendously and working tirelessly without medical assistance and with unmatched scorn.

      Basically, your assertion that the liberation movements of the 60s/70s have been successful is plainly wrong. Your assertion that they could be successful by building a community of supporters is wrong, as their greatest successes occurred when they spearheaded their own actions, built alliances with others and in doing so developed more sophisticated theories of power/oppression, or when those “supporters” who saw their privilege and participation in injustice system worked to abstain from their participation and took action in solidarity. Finally, I see little evidence in the role medicine, particularly psychiatry has played in advancing these movements. I do see the remnants of these movements still dealing with the pain/loss due to the poor interventions (and lack of helpful ones) of those with a lot of power/prestige who are used to getting what they want who thought they knew better about people’s lives than they did (doctors/psychiatrists). I don’t like lumping psychiatrists together as a group, but I do think it is important to conceptualize psychiatry as an institutional force from which psychiatrists gain particular privilege/powers at the expense of limiting/controlling others, can influence societal level discourses, and can be influenced by economic and political forces. Individual psychiatrists could play a role in social justice and human rights, but part of that is understanding how being a psychiatrist shapes someone’s experience, relationships, and power, and how that professional role is deployed in maintaining unjust/oppressive systems (unwittingly or not). If you are not ok being led by folks whose lives have been shaped by their experience of oppression, then at least just work to challenge your colleagues and yourself too assess their own participation in maintaining oppression and think about any ways you can change yourselves. If you can’t do these things–listen, be critical of your own experience and change to act more ethically, follow in solidarity–then better to just get out of the way, as well-wishing intervention in justice movements without having the interest/willingness/capacity to do so just limits the potential power of the movement. I feel like I sound harsh in saying this, and I do appreciate your continued willingness to participate in this dialogue. I just think you have been putting out a lot of thoughts/ideas without first taking the lead from the folks who have not only had bad experiences, but recognize the problematic systemic nature of those experiences.

    • Steve Moffic says: “There are psychiatrists who will join the cause if you let them and quit bashing us as a group.”

      Assuming for time being that this is true, I believe we should leave the door open for these doctors. Doctors can persuade other doctors.

      • Loren Mosher, M.D. never got the memo -

        http://www.moshersoteria.com/articles/resignation-from-apa/

        The REAL reformers have made a clean-break…
        And have had done plenty of their own bashing!

        There’s a reason why Peter Breggin, M.D. is called the “conscience of psychiatry”!

        He never sat around and asked people to stop bashing his profession… He did (and continues to do) the bashing himself!

        Why?
        Because he has a conscience!
        That’s why!

        Whining.
        I’ve grown tired of whining!

        Duane

        • Real reform?

          Look at what’s taking place in foster care; elderly in nursing homes; veterans…

          Young children… infants, sometimes on psychiatric drugs… given ECT!

          1 in 10 Americans on antidepressants. (“Worse than worthless” according to Marcia Angell, M.D)

          1 in 5 on some form of psychotropic drug (chemcial lobotomies, many of them).

          And where has the vast majority (99 plus percent) of the field of psychiatry been?

          SILENT.

          That’s where!

          Managed care?
          Managed care?

          That’s what you want to talk about…
          Managed care?!

          Go ahead.
          Talk about it.

          I’m out.

          Duane

          P.S.: REAL reformers reform!

  7. Every successful liberation movement has formed coalitions with other oppressed groups and also with allies who are members of the oppressing group. Every successful liberation movement has also had to contend with the problem of pseudo allies. These are members of the dominant group who view themselves as champions of the rights of the marginalized because it meets their need to feel helpful or important or in order to make a name for themselves. Pseudo allies typically talk a good line but fail to challenge the power structures which underlie and perpetuate the oppression or to renounce the privileges and benefits that come from being members of the dominant group. Often they mean well. Fortunately, there are also true allies and meaningful and powerful coalitions can and do form. I am speaking here about the dynamics of liberation movements in general. Examples abound.

    Regarding issues of mental health liberation I want to be clear that I do not think all psychitrists are bad. On the contrary, there are psychitrists whose work I admire greatly and who have earned my trust, respect and admiration. One in particular has helped me personally and I am genuinely grateful to him.

    Steve, I hope that you realize when I have challenged you here it is not because you are a psychiatrist. It is because I disagree with your views. You will note that even your most ardent critics here have expressed appreciation for other psychiatrists from time to time. For example, I just read that Anonymous replied to Dr. Steve Balt’s take on diagnosis with a “sounds good.” Clearly the criticism you have received represents more than a general condemnation of all psychiatrists or an unwillingness to forgive, be nice, and move on.

    I will conclude by highlighting an issue on which Steve and I emphatically agree. Readers who want to understand his perspective should not rely on isolated quotes but read the full texts of his pieces in order to make up their own minds.

    • Pseudo allies also dangle possible support in exchange for desired behaviors, rather than simply giving their support because they believe it’s the right thing to do… Just forgive us and be nice and maybe we’ll do something to help you… (or let you out of the institution someday, maybe…)

        • In that article, Steve Moffic wrote:

          “Ignoring this controversy poses at least two potential problems. One is that the medications may have longer long-term risks to the brain and body that we knew before. The other is that patients who stop medications suddenly, as they often do, may have severe withdrawal symptoms and/or a return of their symptoms with even more intensity.

          Now, the jury is still out about these long-term risks….

          So, here’s how I might respond post-Whitaker’s book, and even tell the patient if they don’t ask, all the meanwhile being careful not to scare them away from taking the medication when they really need it….

          “I would recommend that you try this medication for this problem, but only for as long as necessary. At some point of time, we might want to try you off of it, but when we do so, taper the dose very slowly. Please do not stop the medication all at once on your own, because your body and brain will not have time to readjust. In addition, sometimes there is a so-called placebo effect when first starting medication.”….

          Guys, this is the moderate viewpoint.

          Giovanni Fava, whom Robert Whitaker cites often, is advocating for a limit of 6 months on antidepressant treatment.

  8. Steve,
    Pardon me for getting back “on topic” of managed care and human rights violations. These other topics are very important as well. I wasn’t sure where to barge in.

    I am concerned about the conflicts of interest inherent inside health care delivery systems that are also insurance corporations. They decide who gets what kind of care and what to reimburse themselves for. They access both “member” (premiums and co-pays) and government dollars.

    These corporations own the doctors, nurses, labs, pharmacies, hospitals, clinics, pharmacists and all the treatment paths for their millions of “members”. In addition they are responsible to stock prices and dividends that are included in retirement investment plans nationwide.

    I read that one such company has 80 million “members”. In a country of 311 million, this is BIG. Do the old fashioned anit-trust laws work here?

    These systems are enormous interwoven lumps of “capital” in the hands of few. Should we be trusting this process and these few? Do we have any other choices?

    Thanks for writing,
    Alice

    • It seems obvious to me that no, we should not be trusting these entities and these few and yes, we do have other options. Improved Medicare for All comes to mind. I think singlepayeraction.org is an outstanding group. MDs might want to join the madashelldoctors.com if they haven’t already.

      I think the deplorable state of the US healthcare system in general is a case study of the dangers of co-opt able reform. It shows the need to challenge underlying power structures and corporate and government corruption instead of making superficial changes that leave the underlying problems intact.

    • The problem is not “capitalism”.
      The problem is “cronie capitaism”.

      The drugmakers and the federal government are in this together. That’s the problem.

      And expecting to turn the keys over to the government at this point will only make things WORSE… Not better.

      We need to begin to INSIST that Congress take action to prevent the monopoly that’s taking place… The ‘one-size-fits all’ mental health system.

      And we need to hold their feet to the fire!

      There is a way out of this mess, but it’s not about who pays (we all pay)… It’s about WHAT we are paying for!

      Duane

      • Does anyone actually believe that a single-payer system is going to give us more choice?

        Really?

        So, the same federal government that gave us the FDA, the NIMH is suddenly going to begin to police itself and do the right thing?

        Dr. Peter Breggin says that there will be MORE drugging in a socialized system.

        I agree.

        We need a free market to allow for more options.
        The problem is when it comes to mental health care, there has been no free market.

        It’s been cronie capitalism.
        And tyrannical.

        WE can change the system.
        If we DEMAND it be changed.
        But we have to DEMAND that it be changed!

        Duane

        • Re: Socialized medicine is not the answer

          Maybe some folks in the UK or other parts of the world would like to chime in on mental health “treatment” under a single payer plan.

          I have a funny feeling that my comment may result in the opening of’Pandora’s Box’.

          My response are the words to a song(as politically incorrect as they may appear):

          I’m a man of my convictions
          Call me wrong
          Call me right
          But I bring my better angels
          To every fight

          You may not like where I’m going
          But you sure know where I stand
          Hate me if you want to
          Love me if you can -

          http://www.youtube.com/watch?v=mhcfFekSbHQ

          Duane

          P.S.: In my opinion, the success of this “revolution” will not take place, until we begin to embrace those with conservative and libertarian thought, and welcome them into the tent; because the answers lie in the Constitution of the United States.

  9. I agree the US health system is a mess and managed care leads to many barriers to good medical care in many fields.

    BUT managed care could be abolished tomorrow, single payer could be paying top dollar so doctors can spend more time with their patients and, while internal medicine might improve, the problems in psychiatry would still remain.

    At the core of the issue is that almost everything psychiatry knows is wrong. Research in the last 20-30 years is so compromised by commercial interests that there is no real evidence base for any type of invasive psychiatric treatment.

    Encouraging psychiatrists to provide non-drug treatment only diverts them from less destructive courses. Few have the talent and, increasingly, the training, for psychotherapy.

    Where I live, many psychiatrists do not take insurance at all, you can be paying vast sums out of pocket, and a good psychiatrist is still one in 100. That might even be generous. (There are about 800 psychiatrists in my area. Try and find those 8 doctors.)

    Paying psychiatrists more does not erase the nonsense on which they base their diagnoses and treatment recommendations, it only enriches them. Will that make them less lazy when it comes to self-education and critical thinking? I doubt it.

  10. Thanks for all the comments over the weekend, especially a bit of diversity of opinion. I hope we can get more comments from people have tend not to comment.

    Personally, I think for-profit managed care is an enormous problems and influence on all health and mental healthcare. These companies, Alice, are not subject to anti-trust laws and in fact are protected by ERISA laws (self-employed insurance), whereas physicians can not join together in many ways due to anti-trust laws. I think we need at least a public option sometime and a single payor system in the future.

    I know so many who respond here will disagree with this, but most of the psychiatric medication is prescribed not by psychiatrists and prescribed even less well (for indefinite periods without much follow-up). Psychiatrists are an easy target, but not the bullseye here. Sure, some psychiatrists seemed valued here, but mainly ones who agree wholeheartedly with their critics.

    • Dr. Moffic,

      How about the APA and other organized psychiatrists work with the AMA and other medical specialties to reduce psychiatric medication prescription by internists, family doctors, pediatricians, and OB/Gyns. This seems like territory where psychiatrists could take a leading role due to their expertise/respect as specialist physicians, have access and influence that mental health justice movements typically can’t, hopefully lead to some pragmatic changes. These could be:

      1. reduce unnecessary psychiatric medicating.
      2. limiting length/tapering of medication regiments that are not/no longer indicated.
      3. An opportunity to show that psychiatrists manage medications better than other doctors.
      4. Greater movement in designing effective and efficient referral systems for people in distress who present to primary doctors to access a wider range of services beyond pharmaceutical.

      These aren’t particularly radical shifts, lead to robust outcomes, or address the more fundamental critiques of psychiatric practice, but I think it’s a rational reform approach to an uncritical mental health system that would at least reduce needless risk of harm that psychiatrists could lend their unique position/access to alleviate a problem without all that much professional risk.

      Managed care is another area where doctors have a lot more clout than patients/survivors. It is a justice issue that insurance companies are protected from anti-trust laws and there are obstacles for doctors to organize. Doctors still have a lot more public support than insurance and pharmaceutical companies, and I bet could lead their own push with patients supporting to confront the unjust setup. Psychiatrists have a lot of trouble now fighting managed care because they bought in too much to it in order to receive more insurance pay. While other doctors were historically more critical, psychiatrists were more enthusiastic. Perhaps this is another opportunity for doctors across specialties to align against the problems of managed care and how they might grow in the future.

      • That is an excellent idea, Nathan.

        Problem is, there are no studies showing psychiatric care by psychiatrists is safer and more effective than care by any other type of physician.

        To do that, psychiatry would have to look at outcomes for itself as well as others. Ooops!

        (As David Healy says, “psychiatric medication saves lives” is the APA death wish.)

        As far as managed care is concerned, what I pin my hopes on is that it will balk at paying for psychiatric medication. Medicaid may review neuroleptic prescriptions for small children (IMO, a crime against humanity). Workman’s Comp auditors are questioning psychiatric polypharmacy cases (as we all should) to reduce outlays for drugs.

        Psychiatrists will hate this restriction on their freedom to pour whatever chemicals they want into their patients.

        Nathan, what do you mean by
        2. limiting length/tapering of medication regiments that are not/no longer indicated.

        I agree patients should be taken off medications “when no longer needed” (good luck defining what that means), but why limit length of tapering? Some people need very slow tapering to avoid neurological damage.

        • Hi Alto,

          “Problem is, there are no studies showing psychiatric care by psychiatrists is safer and more effective than care by any other type of physician.

          To do that, psychiatry would have to look at outcomes for itself as well as others. Ooops!”

          Because I hear Dr. Moffic and others implicate the fact that non-psychiatrists are often the primary prescribers of psychiatric medications as the rationale for their limited clinical efficacy and harms people who take them experience, limiting prescriptions by non-psychiatrists should by this implication lead to better health outcomes with better risk management of people who take psychiatric medications. We could have some clinical evidence or counter-evidence for this implication. Though I obviously prefer more direct, experimental comparison studies assessing outcomes of patient health being prescribed meds by psychiatrists vs. others, I don’t have much expectation that this will be studied so systematically anytime soon or that they would be ethical given the limited efficacy of many medications to begin with.

          “Nathan, what do you mean by
          2. limiting length/tapering of medication regiments that are not/no longer indicated.’

          In my often confusing language that combines a lot of ideas into one sentence without being all that clear, I inadvertently led you to a conclusion I did not intend. I meant to say that “limiting length of medication regimens AND tapering of medications regimens that are not indicated AND/OR no longer indicated.” or even more clearly ” Limiting length of medications that are not indicated, limiting length of medication regimens that are no longer indicated, tapering of medication regimens that are no longer indicated, and tapering of medications that are no longer indicated.” I do believe safe tapering is key for avoiding more problems from ineffective treatments and that not tapering safely can undo gains of people who experienced treatment as helpful. I think that people should be what are called active/management stages of medications for as limited time as possible, begin tapering as soon as possible, and allow as much time as safely needed to taper off medications. Thanks for calling it to my attention.

          • Nathan, you said “limiting prescriptions by non-psychiatrists should by this implication lead to better health outcomes with better risk management of people who take psychiatric medications”

            There is no evidence for that assumption, which is based entirely on professional pecking order — specialists assumed to know more than generalists.

            In my opinion, the difference in psychiatric treatment by non-psychiatrists vs psychiatrists is that the former diagnoses and prescribes randomly while the later diagnoses and prescribes arbitrarily.

          • Hey Alto,

            I agree. I am just repeating the refrain I often hear from psychiatrists. The potential outcome of psychiatrists taking action against non-psychiatrist precribers of psychiatric meds gives them an opportunity to show some evidence, one way or the other. The quote you took from my piece is an hypotheses that I hear psychiatrist assert but refuse to test. I think they should test it. I don’t expect the outcomes between prescribers to be all that different, given the the limited efficacious results of the efficacy studies on the drugs themselves.

  11. Yes, yes, yes to your recommendations about psychiatrists and family doctors regarding medication prescribing. Indeed, there is a strong push by psychiatrists for more “integrated” medicine and psychiatry.

    I do think, however, and explained this more in my book The Ethical Way, that psychiatry fought managed care much more than the rest of medicine, mainly because we were a major target and had our freedom and reimbursement reduced much more than other medical specialties. I know that some will feel that was well-deserved.

    • Psychiatrists kept prescribing privileges pretty exclusive in relation to other mental health professionals and are able to make very good livings prescribing medications using an invalid diagnostic system from which the APA makes huge profits for mantaining. I think that psychiatrists have been terrible at demonstrating evidence of the efficacy and effectiveness of what they do (medication management and mostly psychodynamic/eclectic psychotherapy), if they do it better than people who are less trained and are payed less than they are, and slow at adopting practices that have shown some targeted efficacy with lower risk.

      There are strong cost saving arguments to be made to government-supported profit-focused managed-care companies (quite the conglomerate of many interests now) about reduced overall health costs if people can access effective psychiatric care if psychiatrists or anyone could actually demonstrate psychiatric care was robustly and reliably helpful and that receiving care was cheaper than the more expensive than hospitalization, loss to productivity, and related negative physical healthcare costs. Build a case using strong evidence for effectiveness and efficiency of treatment and you could build a stronger base of support to pressure managed care. Good luck!

      • I agree, Nathan. You would think psychiatry would try to defend its turf with arguments related to greater effectiveness and safety, leading to cost savings.

        However, psychiatry hasn’t produced a peep in this regard. Instead, as David Healy pointed out http://davidhealy.org/professional-suicide, this statement by the APA in 2004 reveals a death wish:

        “The American Psychiatric Association believes that antidepressants save lives.”

        noting that the APA is not claiming such benefits for psychiatrists but for the drugs themselves, which can be prescribed by anyone.

        (In a puckish later post, he likens the APA’s position to autoerotic asphyxiation.)

        I hope Steve Moffic will explain, perhaps in a future blog post, how “integrating” psychiatrists into medical care will improve outcomes and patient safety.

  12. Just briefly in response. For whatever reason and for whatever worth), research indicates that psychiatric medications have as good result as many medical medications (for hypertension, etc).

    Integration would allow psychiatrists to help other doctors prescribe better or less. Having other physicians in mental health clinics would help to address ignored medical problems, including side effects. Our mind and body works together, doesn’t it?

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