“What is Wrong with the Patient?”Part III

Treatment Approaches:

“What can/should be done for the Patient?”

Overview of Different Treatment Eras

The 1st Biological Psychiatry: 1880s-1920s

The Psychoanalytic Hiatus: 1920s-1960s

The Rise of the 2nd Biological Psychiatry: 1950s-1980s

The Rise of (Cosmetic) Psychopharmacology: 1990s-present

The 1st Biological Psychiatry

• Industrialization and the necessary “medicalization” of mental health and psychiatry in late 1890s and early 1900s

• major advances in understanding biological origins of many several mental illnesses first occurred in Europe (France, Britain, and especially Germany) . . . definitely not in America

e.g., neurosyphilis and “madness”- end stage of neurosyphilis was treated in public asylums and clinics

- “shameful” disease meant most people did not receive treatment for it

- evolution of disease took on mental symptoms of increasing severity

The 1st Biological Psychiatry

• neurosyphilitic madness

No other disease in which primarily

middle-aged men (mainly whites)

suddenly became demented and then

died paralyzed with terminal convulsions.

• flooded European mental asylums in the 19th century, along with an extraordinary increase in patients with severe alcoholism and those with schizophrenia

The 1st Biological Psychiatry• Advanced link between neurology and psychiatry found in

European mental asylums by clinicians who tracked the progression and resolution of these mental diseases

Emil Kraepelin (1856-1926)

- kept data cards on each patient

- “discovered” schizophrenia and

manic-depression

worked with Aloys Alzheimer at the Heidelberg Clinic- they began to spot distinct and predictable patterns of disease progression by virtue of both mental and physiological symptoms

The 1st Biological PsychiatryKraepelin’s ultimate dichotomy of insanity:

(1) those with an affective component (had better prognosis)- mood disorder: depressed, manic, anxious

“manic-depressive illness”

(2) those without an affective component (had worse prognosis)- psychotic in the absence of an affective component

“schizophrenia”

The 1st Biological PsychiatryKraepelin’s structure insisted that there were a number of discrete

psychiatric illnesses, or diseases, each separate from the next.

• Depression, schizophrenia, and so forth were different just as mumps and pneumonia were different.

“medical model” of mental illness temporarily

adopted by America’s “Kraepelin”: Adolph Meyer

returned to Worcester State Hospital/Asylum

and then moved to Johns Hopkins (1910-1941)

Meyer ultimately rejected Kraepelin’s model

Psychiatrist Adolf Meyer sailing to Europe.

The Psychoanalytic Hiatus• Asylum practice came to be seen as “dead end,” even as the

numbers of patients admitted to them continued to increase.

American psychiatrists wanted to shift the focus of their work to private practice and attract a middle-class clientele.

• Freud to the rescue (trained as a neurologist)

Freud: repressed childhood sexual memories and fantasies caused neurosis (or psychosis) when reactivated in adult life.

Leisurely introspection became the form of treatment.

The Psychoanalytic HiatusAmerican origins: 1909 visit by Freud to Clark University

• Key catalyst: “The Arrival of the Europeans” in the 1930s

Years of triumph: late 1940s to late 1960s

• Symptoms were meaningless because disease entities didn’t mean anything when it came to mental illness

Practically everyone had some measure of mental maladjustment.

Question: What else made psychoanalytic and dynamic psychiatry so popular?

The Psychoanalytic Hiatus

deep insulin coma therapy, ECT

Metrozol shock therapy, lobotomy

The Rise of the 2nd Biological Psychiatry1949 - Lithium* (not FDA-approved until 1970)

1954 - Chlorpromazine (Thorazine)

Reserpine

1955 - Meprobamate (Miltown)

1957 - Haloperidol (Haldol)

1958 - Imipramine (Tofranil)

Iproniazid (MOAI)

1960 - Librium (Valium)

1961 - Methylphenidate (Ritalin)

Leo Sternbach, inventor of Valium, died on September 28, 2005, aged 97

The Rise of the 2nd Biological Psychiatry• Deinstitutionalization en masse from early 1960s to early 1980s

• Community Mental Health Centers Act (1963)

• turmoil in the 1970’s and the publication of the DSM-III (1980)

The Rise of PsychopharmacologyType of Coverage 1988 1993 1995 Indemnity (fee-for-service) 71% 49% 30% Managed Care (HMO, PPO) 29% 51% 70%

Managed Behavioral Health (“Carve Outs”)

Because “supply drives demand” in health care ->

Number of Acute Care Hospital Beds/per 1,000 Residents

Source: Dartmouth Atlas of Virginia

Number of Hospital Discharges for all Medical Conditions (DRGs)

Source: Dartmouth Atlas of Virginia

10.010.0

20.020.0

30.030.0

40.040.0

50.050.0

60.060.0

70.070.0

80.080.0NYU Medical Center 76.2

UCLA Medical Center 43.9NY Presbyterian Hospitals 40.3

Cedars-Sinai Medical Center 66.2

Mount Sinai Hospital 53.9

UCSF Medical Center 27.2Stanford University Hospital 22.6

Average number of physician visits per patient during last six months of life who received most of their care in one of 77 “best” US hospitals

Source: John Wennberg (2005)

Empiricism Driving Managed CareResearchers’ and Insurers’ Conclusions:

(1.) Physician practice styles vary considerably, especially regarding diagnoses for which treatment decisions are not driven by consensus on appropriate care and it is not possible to obtain evidence-based guidelines from reading journals or consulting textbooks.

e.g., back surgery rates (the #/per 1,000 Medicare beneficiaries):

- 7/per 1,000 in Naples, FL

- 2/per 1,000 in Hanover, NH

- 4.5/per 1,000 national average

(2.) In medicine, supply generally creates its own demand (e.g., # of hospital beds/per capita, technology available, # of specialists/per capita).

Rates of four orthopedic procedures among Medicare enrollees in 306 Hospital Referral Regions (2000-01)

0.2

1.0

4.0

HipHipFractureFracture

KneeKneeReplacementReplacement

HipHipReplacementReplacement

BackBackSurgerySurgery

Stan

dard

ized

rat

io (

log

scal

e)

Source: John Wennberg (2005)

R2 = 0.49Vis

its

to C

ard

iolo

gist

s p

er e

nro

llee

Vis

its

to C

ard

iolo

gist

s p

er e

nro

llee

0.00.0

0.50.5

1.01.0

1.51.5

2.02.0

2.52.5

0.00.0 2.52.5 5.05.0 7.57.5 10.010.0 12.512.5 15.015.0

Number of Cardiologists per 100,000 residentsNumber of Cardiologists per 100,000 residents

Association between cardiologists and visits per person to cardiologists among Medicare enrollees (1996): 306 HRRs

Source: John Wennberg (2005)

Discharges forHip Fracture

R2 = 0.06

Discharges forall MedicalConditionsR2 = 0.54

00

5050

100100

150150

200200

250250

300300

350350

400400

1.01.0 2.02.0 3.03.0 4.04.0 5.05.0# of Hospital Beds/per 1,000 Residents# of Hospital Beds/per 1,000 Residents

Dis

char

ge R

ate

Dis

char

ge R

ate

Association between # of hospital beds per 1,000 residents (1996) and discharges per 1,000 (1995-96) among Medicare enrollees in 306 HRRs

Source: John Wennberg (2005)

Dilemma & Running Debate• Type 1 errors (fear of “medical malpractice” cases and “self-medicating”)

(person has a mental disorder but is not diagnosed)

• Type 2 errors (fear of “cosmetic psychopharmacology”)

(person does not have a mental disorder, but is diagnosed with one)

Kate Russell for The New York Times

Sarah Couch, who has bipolar disorder,

opposes the effort to force treatment on the mentally ill.

De'Nora Hill: "I am living in fear and I want it to end."

Andrea Yates & Post-Partum Depression w/psychosis