Wednesday, February 15, 2012

Is the Mental Illness Epidemic a Medical or Economic Problem?

If you study things long enough, you can anticipate…
For example, if you listen to enough Barack Obama speeches, you can feel pretty confident you will at some point come across the phrase, “Let me be clear…”
I considered this phenomenon on reading the recent excellent two-part article, “The Epidemic of Mental Illness: Why?,” in The New York Review of Books (Part I: 6/23/11; Part II: 7/14/11) by Marcia Angell, MD, a well-known academic physician who is, among other distinctions, a former editor of The New England Journal of Medicine. Angell, reviewing three fresh books on the subject, investigated the putative benefits of psychotherapeutics (neuroleptics, anti-depressants, etc.), and even the reputed reality of psychiatric diagnoses.
And on starting to read, I knew, with a high level of confidence, that at some point in her review, Angell would say something to the effect that “more research has to be done.”  Sure enough, the last sentence of the penultimate paragraph of the second-part of her review starts, “More research is needed to study…”
I knew this would appear because, as I said, Dr. Angell is an academic physician, and this is how academic physicians make money—they get grants, sometimes from businesses but mostly in today’s culture from the tax-payer, to investigate matters they wish to investigate. In Dr. Angell’s ideal world, patients compliantly do what doctors tell them, and tax-payers compliantly pay for what doctors do, be it studies, procedures, surgeries, or (above all) research conducted by academic physicians, often designed to tell other physicians in the trenches how to practice—what is “appropriate care.” It’s a Platonic, hierarchical system with Dr. Angell and her friends at the pinnacle, the physician-kings.
A decade and a half ago, Dr. Angell and the NEJM were among the great champions of “Hillarycare.” More recently, she has supported “Obamacare.” Her view of good medicine includes a single-payer system, with health-care divorced (she might say “released” or “freed”) from banal concerns over cost.
And this is the great irony of her excellent recent review. Because the many problems she points out regarding the growth of mental illness diagnoses and the risk of ineffective psychopharmaceuticals are fundamentally not problems of medicine. They are problems of economics, and they would be magnified, not eliminated, by the single-payer system Dr. Angell herself supports.
The story Angell tells in recounting the recent exposes of modern psychiatry is one where doctors don’t understand the underlying mechanisms of the supposed diseases they allegedly treat, don’t understand how the medications they administer work, and don’t really care as long as symptomatic relief is achieved (which, in the case of psychoses, often means not so much that the patient feels better but that the people around the patient feel better…). She notes, in recounting the work of psychologist/researcher Irving Kirsch (The Emperor’s New Drugs: Exploding the Anti-Depressant Myth) and journalist Robert Whitaker (Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America) that many of these drugs—heavily pushed by the pharmaceutical industry—work no better than placebos. That is to say, these drugs may work no better than (many) herbs.
Which leads one to ask: Herbal medicine is big business. Herbs are now sold not only in herbal medicine stores, but even in Walmarts and regular supermarkets. Tens of millions of people take herbs as a substitute for or in addition to regular medicines. Hundreds of millions of dollars are spent. Yet we don’t see the problems in the selling of Ginkgo biloba and St. John’s Wart that have developed in the selling of Prozac and Chlorpromazine.
As Angell says in her introductory remarks, “It seems that Americans are in the midst of a raging epidemic of mental illness, at least as judged by the increase in the numbers treated for it.” Yet we see no epidemic in the use of St. John’s Wart…no concern need be raised over those choosing to self-medicate with Ginkgo biloba. If both categories—psychopharmaceuticals and herbal remedies—work no better than placebos, why is one category simply rising and falling with market demand while the other is growing as a “raging epidemic?”
Dr. Angell raises two concerns in her review. One is that psychopharmaceuticals, despite being widely prescribed and used, are not really efficacious. The other is that mental illnesses, due to industry and other financial incentives, are multiplying without regard to underlying medical justification. The irony is that both problems, although they sound medical, are really economic in nature. And they apply more broadly than the good doctor is willing to consider.
Why is it a problem if a depressed patient feels better after taking a placebo? Why is it a problem if a depressed patient feels better after going to a comedy club? It’s a problem because of third-party payers. If psychiatrists claimed that depression could be cured by visiting comedy clubs, and patients felt that therefore the expense of attending comedy clubs should be covered by their health insurance carriers, we could expect certain consequences. First, we could expect objections by the carriers. Second, we could expect a marked increase in claims of depression among those Americans who enjoy attending comedy clubs.
This is of course more problematic when we discuss treatments, especially medications, for diseases whose very existence is merely a function of a psychiatrist’s claim, but similar problems exist even for diseases outside of the psychiatrist’s couch, or domain. More and more vaguely defined diseases—from chronic fatigue syndrome to fibromyalgia to restless leg syndrome—are defined without clear pathologic correlates, based solely on presentation and exclusion of more well-defined disease entities. 
Why is it important, today, for all physicians, not just psychiatrists, to make specific diagnoses, even when it requires linguistic creativity more than diagnostic savvy? Why is it important to say to a perplexing patient: “You have chronic fatigue syndrome,” say, rather than reporting, “You seem chronically fatigued; I have no explanation for your symptoms.”? Could it be because third-party payers pay by diagnosis? Could it be that a physician is concerned he won’t be paid without registering, not diagnosis and treatment, but an established ICD10 code? These codes have exploded in number in the last generation [1], as more and more diseases, both inside and outside psychiatry, have been discovered—invented?—to the point where no one is now told, on presenting with complaints, “don’t worry; you have nothing wrong with you.”
Why are there ICD codes in medicine, but not in other businesses, like restauranteuring? It’s because one needs “objective” criteria to bill third-party payers. It’s not enough to merely have, as in a 5-star restaurant, a satisfied clientele. You could practice at the Mayo Clinic or Boston’s Massachusetts General Hospital and yet mere reputation for high quality will not suffice. You still need the codes. And when your payment hinges on the codes, bewildering complaints without clear pathologic basis will no longer do. It’s one thing to repeatedly see a patient who has nothing wrong with them as far as you can tell if they’re paying their bill. It’s quite another if the insurance company is refusing compensation because you can find nothing wrong.
Are there medications that make those diagnosed with fibromyalgia or restless leg syndrome or any other of various infirmities diagnosed without known pathologic correlate feel better? Perhaps. Are they but placebos? And here an interesting question arises: If we allow illnesses, as we always have in psychiatry and are allowing more and more in general medicine…if we allow diseases diagnosed solely on their symptoms, what is the difference between a placebo and a real cure, if both relieve the symptoms?
It doesn’t matter if others call something that makes you feel better a placebo, whether it's chiropractic or cleansing enemas or sugar pills. But it matters greatly who pays for it. Government regulations and tax rules since the 1950s have created an environment where most people don’t pay for their own health care. Over 50% is paid by the government, and most of the rest is paid by nominally private insurance carriers who are highly regulated and restricted by the government. This has a clear effect on incentives, both for patients and practitioners.

The dramatic cost increases associated with third-party payments extend beyond diseases that may not really exist. The Oct 8-9, 2011 Wall St. Journal has a front-page story of a growing problem: doctors gaming the system to maximize their incomes, not constrained by patient cost-concerns. The article discusses spine surgeons who not only do back surgery, but also create their own companies and patent their own fusion devices (each a minor variant of the other), so as to get a double-cut, as it were, in the billing process. Does the patient really need surgery? Will it improve outcomes? Hard to say, but clearly the surgeons marketing their own devices have an interest over and above patient welfare in performing surgery. In a competitive market, this would be handled by second opinions and the patient’s concern that it all is getting too costly. With third-party payers, however, such activity not only persists but thrives. Not surprisingly, failed back surgery (continued, or recurrent, or worsened back pain after surgery for back pain) has become increasingly common… 
Now, if the problem is related to third-party payers, to the need not merely to please the patient but to justify one’s treatment “objectively” to third-parties, is this problem likely to be resolved or to worsen in an environment like Obamacare? The obvious answer is that it will worsen. It would worsen even more under a single-payer system. Yet, ironically, Dr. Angell is a strong proponent of single-payer systems. 
As Thomas Szasz, the iconoclastic psychiatrist whom Angell references obliquely in her review, noted long ago, we live in an age where 'most any complaint is viewed as caused by a disease. Combining the growing list of vague medical diagnoses with the explosion of diseases listed in the latest DSM catalog, it begins to appear as if the entire human condition is one big disease. From stuttering to shaky legs, from bullying to being bullied, from general aches and pains to being a general pain—most any complaint can now get you diagnosed with a disease, and allow a physician to bill for services. These wouldn’t always be services you’d willingly and voluntarily pay for. For some physicians—perhaps Dr. Angell—that’s the whole point.
[1]:  See the Wall St. Journal front page story , and the ensuing letters to the editor.