Interdisciplinary Review of General, Forensic, Prison and Military Psychiatry and Psychology and the related subjects of Behavior and Law with the occasional notes and comments by Michael Novakhov, M.D. (Mike Nova).
The American Psychiatry is nothing without its Psychoanalytic tradition and its depth. Psychopharmacology does not explain the human soul, and it does not even attempt to. Psychoanalysis does not explain it either, but at least it does attempt to, and it searches for its “royal roads”, although very often it is simply lost on the old side streets. At least the Psychoanalysis retained its intellectual independence, as exemplified in its stand on the so called “Goldwater rule“.
American Psychiatry is in a deep crisis, and the American Psychiatric Association, a bureaucratic Stalinist institution, which lost its touch with reality a long time ago, is the part, the parcel, and one of the many reasons for this crisis. Apparently, as I have good reasons to believe, at least until very recently, the American Psychiatric Association was led, run, and governed by the FBI informant at its very top (its former “President”, Carol Bernstein, who is nothing more than the mediocre, treacherous, double-dealing nincompoop, hungry for power). It degenerated and degraded into the total and complete irrelevance and impotence in scientific and the organizational matters. Very logical and even unavoidable outcome in these circumstances.
Investigate this in depth. Clean up and reform the American Psychiatry and the APA (American Psychiatric Association).
An expert panel has released a new report containing recommendations to rectify the severe shortage of psychiatrists and the dearth of mental health services in the United States.
Released by the National Council Medical Director Institute, which advises the National Council for Behavioral Health on issues strongly related to clinical practice, the report, The Psychiatric Crisis: Causes and Solutions, contains a wide-ranging set of recommendations that touch on every area of the specialty, including training, funding, and models of care delivery.
Lead authors Joe Parks, MD, medical director, National Council for Behavioral Health, and Patrick Runnels, MD, co-chair, Medical Director Institute, discussed the report’s recommendations at a press briefing on March 28, where they were joined by Saul M. Levin, MD, CEO and medical director of the American Psychiatric Association (APA).
The number of psychiatrists is plummeting – down by 10% from 2003 to 2013. The average age of practicing psychiatrists is the mid-50s, compared to the mid-40s for other specialties, said Dr Parks.
Furthermore, approximately 55% of counties across the United States currently have no psychiatrist, and 77% report a severe shortage – a situation that is partially due to an increase in demand.
“People want psychiatric services. They know treatment works, and it’s less stigmatizing than it used to be, so people are more willing to accept and seek treatment,” said Dr Parks.
But their search is often in vain. Two thirds of primary care physicians report having trouble getting psychiatric services for patients, so patients often end up in the emergency department.
“There has been a 42% increase in patients going to ERs for psychiatric services in the past 3 years, but most of them aren’t staffed with psychiatrists,” Dr Parks noted.
“So people end up stuck in the ERs for hours and at times days – two to three times as long as for general medical conditions.”
To make matters worse, some hospitals are closing inpatient psychiatric units because they cannot find psychiatrists to staff and run them.
The lack of services and long wait times for these scarce services are taking a toll on patients.
“These are people burdened and suffering from anxiety, from depression. Some of them feel suicidal, and some of them have hallucinations,” said Dr Parks.
Psychiatry has not received the increase in support that some other specialties, such as obstetrics and gynecology, have. Psychiatrists also do not get the same ancillary staff to assist them in tasks such as arranging patient follow-up, he added.
In many cases, psychiatrists are forced to receive reimbursement that is lower than usual. “About 40% of psychiatrists are in cash-only services. Psychiatrists are rushed, and they burn out and leave the profession earlier,” said Dr Parks.
He described the current mental health care delivery system as “old fashioned,” noting that it “has not kept up with modern, data-driven, evidence-based technologies and has certainly not taken advantage of some of the new, innovative social media ways we can reach out and touch patients.”
Another “looming potential problem” is immigration. Some 50% of new psychiatry trainees are foreign medical graduates, and changes in visa requirements by the Trump administration could add to the workforce problems, he said.
If nothing is done about the psychiatrist shortage, the demand for psychiatry is expected to outstrip supply by 25% by 2025.
Becoming a psychiatrist requires 12,000 hours of training, said Dr Levin, who heads the APA, the largest psychiatric association in the world.
According to Dr Runnels, medical students are more likely to opt for a psychiatry residency if the medical school’s psychiatric department offers a highly-rated and relatively long rotation.
“That’s hugely important, and medical schools need to start working on that,” he said. He added that currently, many training “milestones” are “fuzzily or not well-defined.”
Training does not adequately address team-based collaborative care or supervision of clinicians from other disciplines, for example, physician assistants, said Dr Runnels.
“Medication-assisted treatment for addictions is definitely something that most residents get very little exposure to,” he added.
New Models of Care
The expert panel that developed the report included representatives from all areas of healthcare. In addition to psychiatrists, it included CEOs of healthcare organizations, primary and managed care representatives, academic experts, and those representing related professions, such as nursing.
The panel was tasked to develop recommendations that were “specific and actionable – not broad, vague, pie in the sky but things that a payer could do, things that government could do, things that individual psychiatrists could do, and things that the professional organizations could do to relieve this emergency,” said Dr Parks.
The expert panel recommended that the care delivery system be updated so that psychiatrists would operate more as expert consultants and work in teams, said Dr Parks.
“So they would do the essential things only psychiatrists can do and delegate other parts of care and follow-up for patients who are stable, or services that can be provided by other professionals, such as psychiatric nurses or perhaps physician assistants.”
The panel also recommended new and advanced forms of treatment, such as collaborative care and telepsychiatry.
“We should all be advocating for new, innovative models of care, such as telepsychiatry, which can increase access to specialty psychiatric services across the country,” said Dr Levin.
“We would love to see more telepsychiatry, and we would love to see the payment system actually pay for it,” he added. However, he said, it is important to ensure that patients who receive treatment remotely are “always safe” and that if they begin to show signs and symptoms of distress on the psychiatry call, “we are able to get them help very quickly.”
The APA has a toolkit to help educate psychiatrists and other healthcare providers on how to practice telepsychiatry, said Dr Levin. “I think we all see this as one of the ways we are going to be practicing well into the future.”
The panel also wants to see burdensome governmental rules removed. For example, said Dr Parks, a psychiatrist who provides telepsychiatry services in eight states now has to be licensed in all eight states.
As for medical education, the task force recommended that all residents receive integrated care experience and be placed in a range of different settings to broaden their experience with medication-assisted treatment programs and collaboration with other professions.
All of this requires additional funding, which the panel also addressed.
“We are aware that overall, the healthcare system is looking to cut costs, so we want to point out that our call for increased funding for psychiatry was not something we took lightly,” said Dr Runnels.
“However, we want people to understand that our call for increased funding is about helping to save money overall.”
He pointed out that the use of psychiatry services leads to overall reductions in spending on healthcare.
“We believe insurance companies are leaving money on the table by not adequately funding those services.”
Some of the report’s specific recommendations include the following:
Removing barriers to integrated care: Fund technical assistance programs that help develop alternatives to fee-for-service reimbursement models, because chronic physical conditions are known to improve when mental health conditions are managed, particularly among high-risk populations.
Cutting red tape: Streamline administrative paperwork so that physicians can spend more time with patients and that information exchanges between physicians are more attuned to the patients’ needs.
Changing how psychiatrists are paid: Create awareness about behavioral health’s role in the total cost of care, then shift from fee-for-service arrangements to bundled payments to increase the quality of care and reduce the overall cost of care.
Improving confidentiality regulations: Although the recently revised 42 CFR Part 2 confidentiality regulations are advances, they burden psychiatrists by restricting information regarding treatment of substance use disorder, sometimes keeping patients and their families in the dark to protect psychiatrists.
The authors of the report made other recommendations specific to government and payers, healthcare treatment, and advocacy organizations, as well as nurse practitioners, physician assistants, and other stakeholders. The full report is available for download.
Dr Glass is a psychoanalyst and Associate Professor of Psychiatry (Part-time) … Since 1973, the American Psychiatric Association’s (APA) Code of Ethics … for a psychiatrist to offer a professional opinion unless he or she has …
… mental health professionals even outside the purview of the APA that much of … Unlike in the U.S., the cross-pollination of psychoanalysis, social reform, … theorist and one-time head of the AmericanPolitical Science Association, … the Goldwater Rule or our own historical reluctance to share our clinical …
On Tuesday 35 U.S. psychiatrists, psychologists and social workers … and director of the Seattle Psychoanalytic Society and Institute, says she was … how a person’s mental health may affect other people and his or her ability to perform. … the association pointed to a letter published by APApresident Maria …
A psychiatry group told its members they can comment on the mental health of President Trump—going against the longstanding so-called Goldwater Rule, a self-imposed code that prevents the psychiatry community from commenting on the mental health of public figures.
In an email, the American Psychoanalytic Association told its 3,500 members they don’t have to abide by the Goldwater Rule, which states that mental health professionals should not discuss the mental state of someone they have not personally evaluated, Stat News reported on Tuesday.
“We don’t want to prohibit our members from using their knowledge responsibly,” Prudence Gourguechon, past president of the association, told Stat News.
The debate over whether health professionals can comment on Trump’s mental faculties has raged since the president was elected, with several mental health experts arguing that the Goldwater Rule needs more flexibility regards to Trump. An online petition that calls Trump “mentally ill,” started by psychiatrist John Gartner, has received more than 55,000 signatures since April.
Despite the note from the American Psychoanalytic Association, the American Psychiatric Association—which has more than 37,000 members — said on Tuesday that it continues to stand by the Goldwater Rule.
The Goldwater Rule stems from a controversy in 1964, when Fact magazine reported that more than 1,000 mental health professionals said they believed that then-Republican presidential nominee Barry Goldwater was not mentally fit for office. Goldwater successfully sued Fact for libel after he lost the election, leading to the rule’s addition to the American Psychiatric Association’s ethics guidelines.
The American Psychoanalytic Association did not immediately respond to requests for comment.
Who cares about the American Psychiatric (not Psychoanalytic, please read the previous posts and news) Association, its “ethics committee”, its “Goldwater rule”, its prescriptions and its proscriptions, its stupidity, and its little nincompoopy membership?! Just disband them, they push themselves more and more into the utter irrelevance.
American Psychoanalytic Association, a much more authoritative body, said very clearly: discussions on political matters, including the subject of the Presidents mental health issues, is not a matter of clinical practice, and therefore cannot be regulated by the ethical rules pertaining to the clinical practice.
July 6th, 2017
A poll of the Executive Councilors was undertaken June 19-23 after the Austin annual
meeting. Executive Councilors were asked to comment on two things: whether they
endorse the policy that APsaA as an organization speaks to sociopolitical issues only, not
about specific political figures; and whether they support a poll of the membership to
further assess whether the Association should take a public stance on persons.
The poll yielded the following results: 78% of Councilors replied; 100% endorsed the
policy that APsaA as an organization will speak to issues only, not about specific political
figures; 79% opposed a poll of the membership.
The Executive Committee reviewed these results today and decided based on the data not
to survey the membership. APsaA will continue to speak to issues about which it has
something relevant to say.
However, it is important to note that members of APsaA are free to comment about
political figures as individuals. The American Psychiatric Association’s ethical stance
on the Goldwater Rule applies to its members only. APsaA does not consider political
commentary by its individual members an ethical matter. APsaA’s ethical code
concerns clinical practice, not public commentary.
Recent political discussion within our APsaA online communities has broadened to include
diverse opinion. A respectful openness to different points of views is a welcome and
encouraging shift in the direction of the Community Vision that Council unanimously
endorsed in Austin.
Today, APA’s Ethics Committee issued an opinion that reaffirms our organization’s support for “The Goldwater Rule,” which asserts that psychiatrists should not give professional opinions about the mental state of individuals that they have not personally and thoroughly evaluated. The opinion from the Ethics Committee clarifies the ethical principle of the rule and answers several questions that have recently cropped up surrounding its use.
APA member psychiatrists have abided by the Goldwater Rule since it was implemented in 1973. It is so named because of a controversy that emerged during the 1964 presidential election, when Fact magazine published the results of a survey in which 12,356 psychiatrists were asked whether Sen. Barry Goldwater, the GOP nominee, was psychologically fit for the presidency. Out of 2,417 total responses to the survey, 1,189 said that Goldwater was unfit for office. Goldwater eventually won a defamation suit against Fact.
In its opinion, APA’s Ethics Committee asserts that while it is perfectly fine for a psychiatrist to share their expertise about psychiatric issues in general, it is unethical to offer a professional opinion about an individual without conducting an examination. The committee clarified that the rule applies to all professional opinions offered by psychiatrists, not just diagnoses. For example, saying an individual does not have a mental disorder would also constitute a professional opinion.
Three main points form the rationale for the opinion:
When a psychiatrist comments about the behavior, symptoms, diagnosis, etc. of a public figure without consent, that psychiatrist has violated the principle that psychiatric evaluations be conducted with consent or authorization.
Offering a professional opinion on an individual that a psychiatrist has not examined is a departure from established methods of examination, which require careful study of medical history and first-hand examination of the patient. Such behavior compromises both the integrity of the psychiatrist and the profession.
When psychiatrists offer medical opinions about an individual they have not examined, they have the potential to stigmatize those with mental illness.
I touched on these points in my blog post from June of 2016 on the Goldwater Rule, but our Ethics Committee goes into far greater detail with the opinion it offered today. The Committee even offers rebuttals to the some of the most commonly heard arguments against the Goldwater Rule, including concerns centered on freedom of speech and civic duty; professional opinions or psychological profiles solicited by courts or law enforcement officials for forensic cases; and the Tarasoff Doctrine, which states that mental health professionals have a duty to protect individuals who are being threatened with bodily harm by a patient.
I urge you to take a moment to read the full opinion from the Ethics Committee. It is a thorough and well-reasoned explanation on why the Goldwater Rule is more important than ever. The complexity of today’s media environment demands that we take special care when speaking publicly about mental health issues, particularly when what we say has the potential to damage not only our professional integrity, but the trust we share with our patients, and their confidence in our abilities as physicians.