Tuesday, January 14, 2014

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 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.


  1. Great article, but more importantly, after taking the ADHD quiz, I've realized that both I and my cat have the dreaded disease. I'm off to get us both the treatment we need.

  2. Let’s go question by question, just for the purposes of entertainment.
    1) How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? Your Answer: Often
    It’s called losing interest, getting bored, needing some time away, needing some distance, etc.
    Can be also you , not being good at wrapping up.That is not a crime, or disease.
    2) How often do you have difficulty getting things in order when you have to do a task that requires organization? Your Answer: Rarely
    That one I would leave alone. It is not very exciting. Does that mean that OCD and OSPD cannot be comorbid with ADHD?
    3) How often do you have problems remembering appointments or obligations? Your Answer: Rarely
    People (and diagnostic manuals) call it cognitive disorder, neurocognitive disorder, dementia, etc.
    This is my personal favorite:
    4) When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
    Your Answer: Very Often
    And it’s called procrastination.
    5) How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
    Your Answer: Very Often
    That one we can name anxiety.
    6) How often do you feel overly active and compelled to do things, like you were driven by a motor?
    Your Answer: Rarely
    I was tempted to answer “Every time when I have a couple of drinks”, but it did not give me that option.
    In conclusion: “ADHD May Be Likely”
    Poor me! Or stupid me, to go through decades of education without stimulants?
    You might have other ideas and answers to the questions above, but please remember this is not my native language and I did what I could. Without stimulant.

  3. The ADHD screening questions are from the Br. Assoc. of Psychopharmacology web site. The point that is usually missed in a managed care landscape is whether screening offers advantages or not and how to manage the results of screening after they have happened. Managed care companies in many cases are marketing the screening as population wide treatment and it is not even close. Those same companies will see a screening score as an indication for a medication because they have many prescribers who can supply medications rather than provide a more through diagnostic assessment or treatment plan.

    The general reasons for overdiagnosis is over reliance on screening measures and a failure to make a diagnosis that incorporates all of the elements of an actual psychiatric assessment and failure to look at the issue of distress and disability associated with any identified syndrome. A professional student who comes in without any premorbid history who is a straight A student in their professional school by definition does NOT have ADHD and yet many of these students are getting stimulant prescriptions for "cognitive enhancement" rather than ADHD.

    The issue of overprescribing is a complex problem that affects many areas outside of psychiatry like antibiotic overprescribing. In the case of potentially addictive medications it is impossible for many physicians to get the basic information they need to safely prescribe because from the patient's perspective they may have addictive behaviors that are driven by an unconscious process. It is probably time to try to explain that to politicians and regulators who are currently ready to come down on doctors for overprescribing pain medication.

    I agree with you about politics and political activism. It surfaces in the APA from time to time - but not since Harold Eist. Many of the APA moves that we have seen lately like collaborative care seem politically clueless to me.

  4. Good news on the antipsychotic front:

    "A number of recent studies and recommendations have informed and helped optimize the use of antipsychotics. Perhaps most notable among these is the 5 recommendations [1] put forth by the American Board of Internal Medicine Foundation's Choosing Wisely® campaign. The initiative is intended to reduce unnecessary or potentially harmful medical practices. Regarding antipsychotic prescribing, it recommends the following:

    "1. Don't prescribe antipsychotic medications to patients for any indication without appropriate initial evaluation and appropriate ongoing monitoring.

    "2. Don't routinely prescribe 2 or more antipsychotic medications concurrently.

    "3. Don't use antipsychotics as the first choice to treat behavioral and psychological symptoms of dementia.

    "4. Don't routinely prescribe antipsychotic medications as a first-line intervention for insomnia in adults.

    "5. Don't routinely prescribe antipsychotic medications as a first-line intervention for children and adolescents for any diagnosis other than psychotic disorders."

    1. Don't these guidelines suggest something very wrong has been going on in clinical practice?

      "....These results highlight the need for clinicians to (1) carefully select patients who are truly in need of treatment with antipsychotics; (2) consider psychosocial interventions instead of or in addition to antipsychotic treatments; (3) carefully select the antipsychotics -- ideally in a shared decision-making process -- for the treatment of patients' symptoms and disorders, considering their past treatment experiences, attitudes, and preferences; (4) use the lowest effective dose and shortest necessary duration of treatment, but also keep patients with relapsing conditions on appropriate long-term maintenance therapy as needed; (5) consider nonadherence as one reason for suboptimal response, worsening, relapse, or refractoriness; and (6) routinely and proactively monitor and manage antipsychotic adverse effects in order to maximize the benefit/risk ratio....."

      Having to remind doctors to practice medicine in a responsible way is not exactly a triumph.

  5. Very good post (as usual); I would curious to know your feelings on ISEPP (International Society for Ethical Psychiatry & Psychology); also do you have your presentation on the failure of social psychology to deal with the nexus between families and mental illness (if that was indeed the focus) available online in some way?

    1. Sorry, not familiar with that organization.

      If you are referring to my grand rounds presentation on the neglect by psychiatry of social psychology at the University of TN, sorry no, it's not online.

  6. It would be fairly easy to influence APA elections.

    The number of votes in total is very small — I'll bet it's cronies electing cronies. has a link to 2013 results. Looks like only about 5,000 psychiatrists voted. Paul Summergrad, M.D. is the new president-elect with 3,304 (62.1%) of the vote.

    With a good mailing list, this could be swayed. And if a bloc nominated someone of like mind for president, the direction of the organization could be influenced.

    As for overdiagnosis and overprescription, that's the individual clinician's choice. I'm not buying it that doctors are pressured into practicing bad medicine by the stoopid leftist gummint. It's the individual physician's responsibility to know his or her field.

    The question, which of course should be a concern of the APA, is how to continually improve patient safety and outcomes. This would require an honest assessment of deficiencies in clinical practice, which at present APA leadership is devoted to denying. In that way, I'm sure they believe they're serving the interests of their membership.