The American Psychiatric Association: the Good, the Bad, and the Ugly

On his blog Real Psychiatry, psychiatrist George Dawson, put up a post that was highly critical of the American Psychiatric Association (APA) and its current president, Jeffrey Lieberman. He accused the organization of catering to managed care mismanagement of psychiatric benefits with its focus on collaborative care models. The organization has also been criticized for being in bed with Pharma, although it has taken steps to reduce its dependence of Pharma money. Surprisingly, at long last they even eliminated the very popular Industry-Sponsored Symposia at the Annual Meeting, in which drug companies used free food to attract large audiences to highly biased “educational” presentations by their own hired “experts.”

George Dawson, M.D

I agree with a lot of the criticism. I am particularly annoyed by the way the APA gives lip service to so-called scope of practice issues - which really boil down to whether insurance companies will ever pay psychiatrists (who are physicians first) to do more than write prescriptions - while continuing to basically ignore the issue of psychotherapy disappearing from the practice of psychiatrists all across the United States. The fact that psychiatrists are not taking complete histories any more, which leads to frequent bogus diagnoses and the unnecessary and potentially toxic medicating of children and adults alike, also gets little attention.

This situation leads to the question of whether ethical psychiatrists should boycott the APA. I say no, because I think we need to have more good psychiatrists active in the organization. On Dawson’s blog, I got into the following discussion about this issue in the comment session with psychiatrist James O’Brien:

ME: I wonder if there is any way like-minded people can get together with us to better sound the alarm about this travesty of psychiatric "care." Blogs are easy to ignore.

James O’Brien: This was an excellent article. In response to Dr. Allen's question, the answer is for turkeys to stop paying dues to the American Thanksgiving Association.

ME: If that would make the APA change it's policies or even go away, I'd agree. But since they are probably here to stay, we need people on the inside to at least try to keep its negative tendencies in check.

James O’Brien: Dr. Allen, I wish that were a possibility, but the APA is dominated by academics on salary who love theory over reality and don't understand or are indifferent (or even hostile) to the economics of private practice. Paying dues to APA and AMA is selling them the rope to hang us with. 85% of doctors realize this about AMA but for some reason, many private practice psychiatrists have trouble dumping APA even though they should be horrified by Lieberman's comments. And BTW, if you enjoy APA CME activities, you can still attend at a higher cost. Frankly, I think they are pretty basic and you can do better if you shop around. Lieberman is doing more damage to psychiatry than Scientology can dream of doing.

ME: Maybe so, but what's the alternative? A small chance of having an impact is still better than no chance at all.

James O’Brien: You have more chance of getting them to pay attention by hurting them in the pocketbook than changing their minds through dialogue. All APA Presidents in recent years are cut from the same cloth. I don't see why APA has to be a monopoly. Psychologists who were sick of their APA formed the Association for Psychological Science which is a superior organization.

ME: Well, we did have Harold Eist a few years ago. Granted, no one like him since. I just don't think there's enough of us to hurt the APA in the pocketbook, frankly. I wish we had an effective alternative to the APA, but right now there isn't one. As to the psychologists, CBT'ers who grossly exaggerate their evidence base, ignore human relationships, and deny funding to other types of psychotherapy outcome studies still dominate clinical psychology, so I don't know how much good that other organization is really doing. I'm certainly open to anyone with new ideas about how to better get the word out.  

At least at the APA annual meeting, opposing voices do have a forum. Mark Zimmerman presented on the evils of symptom checklists and about patients with borderline personality disorder being misdiagnosed as Bipolar. My colleague from Australia, Peter Parry, presents the other side on pediatric bipolar disorder. I presented on the neglect of social psychology by the field. And folks like us get up and challenge nonsense with questions after stupid presentations. We need more people like us at the meetings, not fewer.

The APA is certainly a mixed lot these days. There’s something for everyone to criticize, especially with Lieberman. On one of my issues, time spent with patients, Lieberman was recently quoted in Psychiatric News, the APA’s newspaper for members: “The psychiatrist of the future will likely have less regular face-to-face time with patients (like our colleagues in other medical specialties)…We will have to do more with less.”

Oh, so short changing and mismanagement of patients is something we just have to accept, perhaps because there’s not enough of us to go around? That is outrageous. As I have said before, accepting such a managed care perspective is just like a cardiac surgeon agreeing to only do single bypass surgery on all patients even when triple bypass surgery is called for. 

If there’s a doctor shortage, let’s do something about that. There has not been an increase in post-doctoral residency training slots since the mid nineties. Society doesn’t want to pay for more? Too bad for them. Not our fault. The answer to the doctor shortage is not to short-change the patients we do see.

Then there is the matter of the skyrocketing number of bogus diagnoses of ADHD and treatment with stimulants in both children and adults, a frequent topic on this blog.  As reported by a recent article in the New York Times:

‘Could you have A.D.H.D.?’ beckons one quiz, sponsored by Shire, on the website everydayhealth.com. Six questions ask how often someone has trouble in matters like “getting things in order,” “remembering appointments” or “getting started” on projects. A user who splits answers evenly between “rarely” and “sometimes” receives the result “A.D.H.D. Possible.” Five answers of “sometimes” and one “often” tell the user, “A.D.H.D. May Be Likely.” In a nationwide telephone poll conducted by The Times in early December, 1,106 adults took the quiz. Almost half scored in the range that would have told them A.D.H.D. may be possible or likely.

These are the questions:

1.     How often do you have trouble wrapping up details on a project, once the challenging parts have been done?

2.     How often do you have difficulties getting things in order when you have to do a task that requires organization?

3.     How often do you have trouble remembering appointments or obligations?

4.     When you have a task that requires a lot of thought, how often do you avoid or delay getting started?

5.     How often do you fidget or squirm with your hands or feet when you have to sit down for a long time.

6.     How often do you feel overly active and compelled to do things, like you were driven by a motor?

As I discussed in my last post, The APA’s own Psychiatric News e-mail alert reported, “The authors speculate that “better detection of underlying ADHD, due to increased health education and awareness efforts,” may be the reason for the increase of ADHD diagnoses among American children.” The more likely explanation - that acting out kids and adult are being saddled with diagnoses made without any evaluation of psychosocial problems - was not mentioned at all.

Still, there are forces in the organization that seem to be paying more attention to things, so good doctors resigning from the organization is counterproductive. The APA has started paying attention to another horrific managed care problem – the response of the industry to the so-called “parity law” passed by the US Congress, which stipulates that insurers must cover mental disorders the same as they cover physical disorders (however bad that coverage is, unfortunately). 

Even Lieberman was alarmed. He was quoted thusly in the 8/16/13 issue of Psychiatric News: “Despite passage of the 2008 legislation, many insurance companies have manipulated its intent and purpose through vague medical necessity standards, lengthy approval processes, bureaucratic delays in service requests, and complicated appeals progress.”  

They have also ratched down fees paid by psychiatrists, leading to many of them resigning from some of their provider panels, so the patient is “covered” but cannot find a doctor!

In terms of so-called medical necessity (whether the insurance company will deem a given service as reimbursable), the insurance companies often would not tell doctors – or its customers for that matter – what standards the company was using to make a decision about that. They called it a “trade secret!”

The APA lobbied the federal government hard to stop these unfair practices with some success, resulting in the recently released final rule regarding implementation of the parity law. Insurance companies at least now have to disclose their standards for determining “medical necessity.” Of course, insurance companies will continue to be ingenious at finding ways to deny care.

So maybe there’s hope for the APA yet. Psychiatrists no longer have the luxury of being politically inactive and letting the APA continue to wander in the proverbial wilderness. Any concerned psychiatrists need to join the organization and let their voices be heard.