Dinah Miller, MD

No topic is quite so controversial in psychiatry as outpatient civil commitment.

We all value the right to make our own medical decisions, perhaps even more so when it comes to issues of mental health. The concern, however, is that some patients lack the ability to see that they are ill, and their refusal to participate in treatment leads them to repeated involuntary hospitalizations or to behaviors that result in their incarceration. Mandated care for forensic patients – those who have ended up in the criminal justice system – is not as controversial, but for those who have committed no crime, the legislative struggles can get very heated. Add to that the cost of implementing outpatient civil commitment (OCC), the difficulties in enforcing the orders, the call to include an array of services for participants, the difficulties in ascertaining if these mandates are successful in helping patients live better lives, and the fact that treatment doesn’t always work, then what seems like a simple solution to the problem of noncompliance is actually quite complex.

Maryland is one of four states that does not have OCC. In 2017, it was announced that the city of Baltimore would begin an OCC pilot program. The program, administered by Behavioral Health System Baltimore (BHSB) in partnership with numerous other mental health organizations, has had several fits and starts. The program initially was funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), and the grant required the program to serve a minimum of 75 patients. However, it was soon discovered that there were no written regulations, and that began a 1-year delay while regulations were written, including two periods for open public comment. Once set, BHSB needed to let local hospitals know the program existed and solicit referrals.

When it became clear that they would not be able to serve 75 individuals, BHSB elected to give its funding back to SAMHSA, and a second 3-month delay ensued until the state of Maryland picked up the cost. The Baltimore pilot project in OCC is different from other civil commitment programs. The criteria for inclusion are brief: The patient must be aged over 18 years, be a resident of Baltimore, and must have been retained by a judge at a hospital inpatient civil commitment hearing at least two times in the past year because of noncompliance with outpatient treatment. The referral needs to come from the inpatient unit before the patient is discharged, and entails a “settlement agreement” with a judge, typically the same administrative law judge that visits the hospital weekly for the inpatient commitment hearings. A connection is made with the patient prior to discharge from the inpatient facility.

The Baltimore project also differs in many ways from traditional outpatient commitment programs in other states. In this program, the patient is not mandated to treatment. Instead, the patient is required to meet with the program’s peer-recovery specialist. The recovery specialist provides support for the patient after discharge, facilitates engagement in both psychiatric and somatic medical care, and helps with transportation to appointments. Services for each participant continue for 6 months; the initial SAMHSA grant was for $2.8 million for 4 years.

Nicole McGill, the program’s monitor notes: “When people are repeatedly hospitalized, it signals to us that maybe the system hasn’t been doing what it needs to do. For those people, the OCC pilot aims to be the connection to existing services in the community.”

Of the 19 people who have been referred to the program since October 2017, 9 have been accepted. Six of those patients enrolled voluntarily; three were ordered into the program against their will. Of those three, one patient has refused to meet with the peer-recovery specialist. That patient, however, is enrolled with an Assertive Community Treatment and is not someone who is refusing psychiatric treatment. That patient was enlisted with the hope that more engagement might prevent future hospitalizations.

“We didn’t want to create a program that forced people into treatment,” said Adrienne Breidenstine, vice president for policy and communications for BHSB. “Those programs don’t work. If a program participant chooses not to engage in services, the OCC peers will step up their engagement. There are no punitive or legal consequences; they aren’t brought back to the hospital or taken to jail.”

So far, the program has been well received by its clients. Feedback is solicited through the Mental Health Association of Maryland. One client provided a testimonial saying: “I didn’t know there were so many resources out there. They took me to the food co-op and gave me free sheets. I got a fan. They didn’t waste time getting me that. It helped a lot with the heat. They get me to appointments. They helped so much.”

This fall, BHSB is expanding its services; as of Sept. 9, 2019, any Baltimore resident who is currently hospitalized and has been hospitalized at least one other time in the past 12 months will be eligible for the outpatient “commitment” program; there will no longer be a requirement that these inpatient stays involved retention at a civil commitment hearing or that the patient ever had an involuntary status. Patients who have not been committed to the hospital, however, will only be able to enter the program on a voluntary track.

This model of OCC is a bit of a misnomer: Most of the patients are in the program voluntarily, and they are not being required to go to treatment or take medications. It is a way to get a higher level of service to the sickest of patients who have needed repeated hospitalizations without the objections that get raised when patients are mandated to care. Given the distress that involuntary hospitalization causes, it may well be helpful to expand a voluntary offer of services to all patients who are retained at a hearing, even if only once; perhaps the added support could prevent future decompensations.

For now, the program has had a rough beginning, and the expense is hard to justify for so few patients. For advocates who support outpatient commitment, this program does not go far enough, as there is no requirement to take medications and no consequence for refusal to participate. As the criteria for inclusion are loosened to include those who are repeatedly hospitalized on a voluntary basis, it will be interesting to see if hospitalizations can be prevented and if the quality of life can be improved for these patients.

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University, 2016). She has a private practice, and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.

No topic is quite so controversial in psychiatry as outpatient civil commitment.

We all value the right to make our own medical decisions, perhaps even more so when it comes to issues of mental health. The concern, however, is that some patients lack the ability to see that they are ill, and their refusal to participate in treatment leads them to repeated involuntary hospitalizations or to behaviors that result in their incarceration. Mandated care for forensic patients – those who have ended up in the criminal justice system – is not as controversial, but for those who have committed no crime, the legislative struggles can get very heated. Add to that the cost of implementing outpatient civil commitment (OCC), the difficulties in enforcing the orders, the call to include an array of services for participants, the difficulties in ascertaining if these mandates are successful in helping patients live better lives, and the fact that treatment doesn’t always work, then what seems like a simple solution to the problem of noncompliance is actually quite complex.

Maryland is one of four states that does not have OCC. In 2017, it was announced that the city of Baltimore would begin an OCC pilot program. The program, administered by Behavioral Health System Baltimore (BHSB) in partnership with numerous other mental health organizations, has had several fits and starts. The program initially was funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), and the grant required the program to serve a minimum of 75 patients. However, it was soon discovered that there were no written regulations, and that began a 1-year delay while regulations were written, including two periods for open public comment. Once set, BHSB needed to let local hospitals know the program existed and solicit referrals.

When it became clear that they would not be able to serve 75 individuals, BHSB elected to give its funding back to SAMHSA, and a second 3-month delay ensued until the state of Maryland picked up the cost. The Baltimore pilot project in OCC is different from other civil commitment programs. The criteria for inclusion are brief: The patient must be aged over 18 years, be a resident of Baltimore, and must have been retained by a judge at a hospital inpatient civil commitment hearing at least two times in the past year because of noncompliance with outpatient treatment. The referral needs to come from the inpatient unit before the patient is discharged, and entails a “settlement agreement” with a judge, typically the same administrative law judge that visits the hospital weekly for the inpatient commitment hearings. A connection is made with the patient prior to discharge from the inpatient facility.

The Baltimore project also differs in many ways from traditional outpatient commitment programs in other states. In this program, the patient is not mandated to treatment. Instead, the patient is required to meet with the program’s peer-recovery specialist. The recovery specialist provides support for the patient after discharge, facilitates engagement in both psychiatric and somatic medical care, and helps with transportation to appointments. Services for each participant continue for 6 months; the initial SAMHSA grant was for $2.8 million for 4 years.

Nicole McGill, the program’s monitor notes: “When people are repeatedly hospitalized, it signals to us that maybe the system hasn’t been doing what it needs to do. For those people, the OCC pilot aims to be the connection to existing services in the community.”

Of the 19 people who have been referred to the program since October 2017, 9 have been accepted. Six of those patients enrolled voluntarily; three were ordered into the program against their will. Of those three, one patient has refused to meet with the peer-recovery specialist. That patient, however, is enrolled with an Assertive Community Treatment and is not someone who is refusing psychiatric treatment. That patient was enlisted with the hope that more engagement might prevent future hospitalizations.

“We didn’t want to create a program that forced people into treatment,” said Adrienne Breidenstine, vice president for policy and communications for BHSB. “Those programs don’t work. If a program participant chooses not to engage in services, the OCC peers will step up their engagement. There are no punitive or legal consequences; they aren’t brought back to the hospital or taken to jail.”

So far, the program has been well received by its clients. Feedback is solicited through the Mental Health Association of Maryland. One client provided a testimonial saying: “I didn’t know there were so many resources out there. They took me to the food co-op and gave me free sheets. I got a fan. They didn’t waste time getting me that. It helped a lot with the heat. They get me to appointments. They helped so much.”

This fall, BHSB is expanding its services; as of Sept. 9, 2019, any Baltimore resident who is currently hospitalized and has been hospitalized at least one other time in the past 12 months will be eligible for the outpatient “commitment” program; there will no longer be a requirement that these inpatient stays involved retention at a civil commitment hearing or that the patient ever had an involuntary status. Patients who have not been committed to the hospital, however, will only be able to enter the program on a voluntary track.

This model of OCC is a bit of a misnomer: Most of the patients are in the program voluntarily, and they are not being required to go to treatment or take medications. It is a way to get a higher level of service to the sickest of patients who have needed repeated hospitalizations without the objections that get raised when patients are mandated to care. Given the distress that involuntary hospitalization causes, it may well be helpful to expand a voluntary offer of services to all patients who are retained at a hearing, even if only once; perhaps the added support could prevent future decompensations.

For now, the program has had a rough beginning, and the expense is hard to justify for so few patients. For advocates who support outpatient commitment, this program does not go far enough, as there is no requirement to take medications and no consequence for refusal to participate. As the criteria for inclusion are loosened to include those who are repeatedly hospitalized on a voluntary basis, it will be interesting to see if hospitalizations can be prevented and if the quality of life can be improved for these patients.

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University, 2016). She has a private practice, and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.

No topic is quite so controversial in psychiatry as outpatient civil commitment.

We all value the right to make our own medical decisions, perhaps even more so when it comes to issues of mental health. The concern, however, is that some patients lack the ability to see that they are ill, and their refusal to participate in treatment leads them to repeated involuntary hospitalizations or to behaviors that result in their incarceration. Mandated care for forensic patients – those who have ended up in the criminal justice system – is not as controversial, but for those who have committed no crime, the legislative struggles can get very heated. Add to that the cost of implementing outpatient civil commitment (OCC), the difficulties in enforcing the orders, the call to include an array of services for participants, the difficulties in ascertaining if these mandates are successful in helping patients live better lives, and the fact that treatment doesn’t always work, then what seems like a simple solution to the problem of noncompliance is actually quite complex.

Maryland is one of four states that does not have OCC. In 2017, it was announced that the city of Baltimore would begin an OCC pilot program. The program, administered by Behavioral Health System Baltimore (BHSB) in partnership with numerous other mental health organizations, has had several fits and starts. The program initially was funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), and the grant required the program to serve a minimum of 75 patients. However, it was soon discovered that there were no written regulations, and that began a 1-year delay while regulations were written, including two periods for open public comment. Once set, BHSB needed to let local hospitals know the program existed and solicit referrals.

When it became clear that they would not be able to serve 75 individuals, BHSB elected to give its funding back to SAMHSA, and a second 3-month delay ensued until the state of Maryland picked up the cost. The Baltimore pilot project in OCC is different from other civil commitment programs. The criteria for inclusion are brief: The patient must be aged over 18 years, be a resident of Baltimore, and must have been retained by a judge at a hospital inpatient civil commitment hearing at least two times in the past year because of noncompliance with outpatient treatment. The referral needs to come from the inpatient unit before the patient is discharged, and entails a “settlement agreement” with a judge, typically the same administrative law judge that visits the hospital weekly for the inpatient commitment hearings. A connection is made with the patient prior to discharge from the inpatient facility.

The Baltimore project also differs in many ways from traditional outpatient commitment programs in other states. In this program, the patient is not mandated to treatment. Instead, the patient is required to meet with the program’s peer-recovery specialist. The recovery specialist provides support for the patient after discharge, facilitates engagement in both psychiatric and somatic medical care, and helps with transportation to appointments. Services for each participant continue for 6 months; the initial SAMHSA grant was for $2.8 million for 4 years.

Nicole McGill, the program’s monitor notes: “When people are repeatedly hospitalized, it signals to us that maybe the system hasn’t been doing what it needs to do. For those people, the OCC pilot aims to be the connection to existing services in the community.”

Of the 19 people who have been referred to the program since October 2017, 9 have been accepted. Six of those patients enrolled voluntarily; three were ordered into the program against their will. Of those three, one patient has refused to meet with the peer-recovery specialist. That patient, however, is enrolled with an Assertive Community Treatment and is not someone who is refusing psychiatric treatment. That patient was enlisted with the hope that more engagement might prevent future hospitalizations.

“We didn’t want to create a program that forced people into treatment,” said Adrienne Breidenstine, vice president for policy and communications for BHSB. “Those programs don’t work. If a program participant chooses not to engage in services, the OCC peers will step up their engagement. There are no punitive or legal consequences; they aren’t brought back to the hospital or taken to jail.”

So far, the program has been well received by its clients. Feedback is solicited through the Mental Health Association of Maryland. One client provided a testimonial saying: “I didn’t know there were so many resources out there. They took me to the food co-op and gave me free sheets. I got a fan. They didn’t waste time getting me that. It helped a lot with the heat. They get me to appointments. They helped so much.”

This fall, BHSB is expanding its services; as of Sept. 9, 2019, any Baltimore resident who is currently hospitalized and has been hospitalized at least one other time in the past 12 months will be eligible for the outpatient “commitment” program; there will no longer be a requirement that these inpatient stays involved retention at a civil commitment hearing or that the patient ever had an involuntary status. Patients who have not been committed to the hospital, however, will only be able to enter the program on a voluntary track.

This model of OCC is a bit of a misnomer: Most of the patients are in the program voluntarily, and they are not being required to go to treatment or take medications. It is a way to get a higher level of service to the sickest of patients who have needed repeated hospitalizations without the objections that get raised when patients are mandated to care. Given the distress that involuntary hospitalization causes, it may well be helpful to expand a voluntary offer of services to all patients who are retained at a hearing, even if only once; perhaps the added support could prevent future decompensations.

For now, the program has had a rough beginning, and the expense is hard to justify for so few patients. For advocates who support outpatient commitment, this program does not go far enough, as there is no requirement to take medications and no consequence for refusal to participate. As the criteria for inclusion are loosened to include those who are repeatedly hospitalized on a voluntary basis, it will be interesting to see if hospitalizations can be prevented and if the quality of life can be improved for these patients.

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University, 2016). She has a private practice, and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.

Bob has been coming to therapy for a few months now. Initially, we met every week, but as his depression lifted, he asked to space the sessions out to twice a month, even as he continues to struggle with many challenges in his life. The cost, he says, is prohibitive, and while Bob believed he had good commercial insurance coverage, he’s learned a few things about insurance and mental health care.

Bob was referred to me by his internist. He knew I did not participate in his insurance network, but his policy covers out-of-network care. He’d had a number of imaging studies and then knee surgery earlier in the year, so he believed he’d met his deductible. He learned that, while he’d met his in-network deductible, he’d had no out-of-network expenses and there was a separate, much higher deductible – one he was not likely to meet with outpatient psychiatric care. In fact, the full cost of his treatment was not being subtracted from the deductible he needed to meet, but rather he was getting credit for lower usual and customary evaluation and management and psychotherapy fees for each session. It became clear that it would be many months – if ever – before Bob could expect any reimbursement for his out-of-network visits.

What Bob didn’t know was that, had he decided to switch to an in-network psychiatrist, he might well have trouble finding one, since half of psychiatrists don’t participate with any health insurance plans. And if he did see an in-network psychiatrist, he would likely need to find a separate in-network social worker or psychologist for psychotherapy, because most in-network psychiatrists see patients for short medication-management appointments. While the insurance companies would give Bob a list of providers, those lists are not kept up to date and include psychiatrists who have died, moved, aren’t taking new patients, or who have retired. The insurance company clearly states on its voicemail that verification of services does not guarantee payment, and Bob was told that the only way he could be certain of the reimbursement would be to submit the claims and wait. He went into treatment fully understanding that he might get no help with the cost from his health insurance.

When I first started in private practice in the 1990s, I joined only one panel. An older colleague told me I was foolish to hesitate, and that soon the panels would fill and it would be too late; psychiatrists wouldn’t be able to get on to the panels and would be unable to attract patients. A few years later, that same psychiatrist withdrew from all the insurance panels he was on; working on their terms was not rewarding. This division of in-network and out-of-network care is crucial to managed care: They must attract panels of doctors who will work for lower rates or with stipulations on how the doctor practices in order to save money.

But managed care came with a price: An entire administration was created to oversee the regulation of treatment. With time, some aspects of care management have vanished; it has been years since I have been asked to fill out a treatment plan to justify a need for outpatient psychotherapy. In Bob’s case, it’s clear how they save money; since he will not reach his high deductible, he will bear the full cost of his psychotherapy. Other patients who cannot afford to go out of network may give up searching and decide to go without treatment – this is not always an easy service to negotiate when one is distressed and compromised. Half of people with serious psychiatric disorders are not in treatment, and barriers to getting care are certainly one reason why.

Many psychiatrists have discovered that they can maintain a practice without being on insurance panels, as managed care only works if there are enough players willing to toss the ball. As psychiatrists have shied away from these panels, insurers have raised their reimbursement rates, and in Maryland, Medicaid also has had to raise their rates. The struggle has become one of how to get enough mental health professionals, and psychiatrists in particular, to join insurance panels in what is a shortage field.

Maybe the question of how to get enough psychiatrists to participate with insurance panels is now the wrong question. Perhaps there are better ways to spend health care dollars than on the administration and management that come with limiting which doctors patients can see. The logistics of in-network versus out-of-network care are an expensive one, and create unconscionable scenarios in other fields. For example, such scenarios include ones in which a patient is brought in for emergency care to a facility where the doctors are not in network, or a patient has a procedure with an in-network surgeon but is unaware that the anesthesiologist or other members of the care team are not on the panel.

What if insurers controlled costs by setting a reasonable fee they would pay for services and paid any licensed physician for these services? Would market forces sort this out? Would fees then set to one which insurers would be willing to pay and physicians would be willing to accept? Or would those who are ill and impoverished be blocked from getting any care? What if we tried a whole new paradigm for psychiatric care?

Richard G. Frank, PhD, is a professor of health economics at Harvard. He specializes in mental health economics and is coauthor of the book “Better But Not Well: Mental Health Policy in the United States Since 1950” (Baltimore: Johns Hopkins University Press, 2006). Dr. Frank is a proponent of insurance panels.

“In the world we live in, we need to have panels; they are essential to controlling cost. They create a balance in terms of cost and utilization control in ways that protect patients, and they create a way for the insurance companies to bargain,” he said.

Dr. Frank noted that the concept that insurers should pay a set reasonable fee to any physician a patient wants to see has been tried. “It’s called ‘reference pricing,’ and when they did that with hip replacement surgery in California, it just hasn’t worked out. Patients ended up getting larger bills than they anticipated.

“The issues with psychiatry are different,” he continued. “There is a lot of bad behavior on the part of insurers and it’s an issue of parity. We shouldn’t let insurers differentially pay psychiatrists less. They have had an incentive to reduce the availability of mental health care and it’s bad for patients. It’s about lower payments to psychiatrists and the way those payments are currently structured drives patients out of care and defeats the purpose of insurance.”

Steven Sharfstein, MD, is the former CEO of Sheppard Pratt Health Systems, a past president of the American Psychiatric Association, and coauthor of several books on the economics of psychiatry. He refers to the current practice of credentialing network psychiatrists as a means of “rationing by supply.”

“The networks create a barrier to accessing care. I don’t think it’s an efficient way to take on the high cost of care, and it creates a tiered system.” Like Dr. Frank, Dr. Sharfstein believes parity is a large part of the problem. When asked about the idea of ending networks and establishing uniform deductibles and reimbursement rates, Dr. Sharfstein replied: “It really depends. We would need fees to hit a sweet spot that supports care while controlling costs.”

One thing is clear: With the current paradigm, it is often difficult to access treatment, and the well-insured patients may bear a significant and disproportionate cost (if not the entire cost) for getting care. Many who need care do not get it, regardless of their insurance status. Our status quo for psychiatric care falls short and I don’t predict that psychiatrists will rush to join networks so long as the demand for psychiatrists is greater than the supply.

Might another financial model work better? We know the system is lacking and one option, as Dr. Frank suggests, is to find solutions within the current model. But perhaps the question should not be one of how to get more psychiatrists to join networks, but of how to rework the system without the assumption that networks are the only way. While Bob is pleased that his symptoms are getting better and he’s managed a way to tackle his own bills, it’s certainly time to explore new ways of delivering and reimbursing psychiatric care.

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle of Inpatient Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016), and has a private practice in Baltimore.

Bob has been coming to therapy for a few months now. Initially, we met every week, but as his depression lifted, he asked to space the sessions out to twice a month, even as he continues to struggle with many challenges in his life. The cost, he says, is prohibitive, and while Bob believed he had good commercial insurance coverage, he’s learned a few things about insurance and mental health care.

Bob was referred to me by his internist. He knew I did not participate in his insurance network, but his policy covers out-of-network care. He’d had a number of imaging studies and then knee surgery earlier in the year, so he believed he’d met his deductible. He learned that, while he’d met his in-network deductible, he’d had no out-of-network expenses and there was a separate, much higher deductible – one he was not likely to meet with outpatient psychiatric care. In fact, the full cost of his treatment was not being subtracted from the deductible he needed to meet, but rather he was getting credit for lower usual and customary evaluation and management and psychotherapy fees for each session. It became clear that it would be many months – if ever – before Bob could expect any reimbursement for his out-of-network visits.

What Bob didn’t know was that, had he decided to switch to an in-network psychiatrist, he might well have trouble finding one, since half of psychiatrists don’t participate with any health insurance plans. And if he did see an in-network psychiatrist, he would likely need to find a separate in-network social worker or psychologist for psychotherapy, because most in-network psychiatrists see patients for short medication-management appointments. While the insurance companies would give Bob a list of providers, those lists are not kept up to date and include psychiatrists who have died, moved, aren’t taking new patients, or who have retired. The insurance company clearly states on its voicemail that verification of services does not guarantee payment, and Bob was told that the only way he could be certain of the reimbursement would be to submit the claims and wait. He went into treatment fully understanding that he might get no help with the cost from his health insurance.

When I first started in private practice in the 1990s, I joined only one panel. An older colleague told me I was foolish to hesitate, and that soon the panels would fill and it would be too late; psychiatrists wouldn’t be able to get on to the panels and would be unable to attract patients. A few years later, that same psychiatrist withdrew from all the insurance panels he was on; working on their terms was not rewarding. This division of in-network and out-of-network care is crucial to managed care: They must attract panels of doctors who will work for lower rates or with stipulations on how the doctor practices in order to save money.

But managed care came with a price: An entire administration was created to oversee the regulation of treatment. With time, some aspects of care management have vanished; it has been years since I have been asked to fill out a treatment plan to justify a need for outpatient psychotherapy. In Bob’s case, it’s clear how they save money; since he will not reach his high deductible, he will bear the full cost of his psychotherapy. Other patients who cannot afford to go out of network may give up searching and decide to go without treatment – this is not always an easy service to negotiate when one is distressed and compromised. Half of people with serious psychiatric disorders are not in treatment, and barriers to getting care are certainly one reason why.

Many psychiatrists have discovered that they can maintain a practice without being on insurance panels, as managed care only works if there are enough players willing to toss the ball. As psychiatrists have shied away from these panels, insurers have raised their reimbursement rates, and in Maryland, Medicaid also has had to raise their rates. The struggle has become one of how to get enough mental health professionals, and psychiatrists in particular, to join insurance panels in what is a shortage field.

Maybe the question of how to get enough psychiatrists to participate with insurance panels is now the wrong question. Perhaps there are better ways to spend health care dollars than on the administration and management that come with limiting which doctors patients can see. The logistics of in-network versus out-of-network care are an expensive one, and create unconscionable scenarios in other fields. For example, such scenarios include ones in which a patient is brought in for emergency care to a facility where the doctors are not in network, or a patient has a procedure with an in-network surgeon but is unaware that the anesthesiologist or other members of the care team are not on the panel.

What if insurers controlled costs by setting a reasonable fee they would pay for services and paid any licensed physician for these services? Would market forces sort this out? Would fees then set to one which insurers would be willing to pay and physicians would be willing to accept? Or would those who are ill and impoverished be blocked from getting any care? What if we tried a whole new paradigm for psychiatric care?

Richard G. Frank, PhD, is a professor of health economics at Harvard. He specializes in mental health economics and is coauthor of the book “Better But Not Well: Mental Health Policy in the United States Since 1950” (Baltimore: Johns Hopkins University Press, 2006). Dr. Frank is a proponent of insurance panels.

“In the world we live in, we need to have panels; they are essential to controlling cost. They create a balance in terms of cost and utilization control in ways that protect patients, and they create a way for the insurance companies to bargain,” he said.

Dr. Frank noted that the concept that insurers should pay a set reasonable fee to any physician a patient wants to see has been tried. “It’s called ‘reference pricing,’ and when they did that with hip replacement surgery in California, it just hasn’t worked out. Patients ended up getting larger bills than they anticipated.

“The issues with psychiatry are different,” he continued. “There is a lot of bad behavior on the part of insurers and it’s an issue of parity. We shouldn’t let insurers differentially pay psychiatrists less. They have had an incentive to reduce the availability of mental health care and it’s bad for patients. It’s about lower payments to psychiatrists and the way those payments are currently structured drives patients out of care and defeats the purpose of insurance.”

Steven Sharfstein, MD, is the former CEO of Sheppard Pratt Health Systems, a past president of the American Psychiatric Association, and coauthor of several books on the economics of psychiatry. He refers to the current practice of credentialing network psychiatrists as a means of “rationing by supply.”

“The networks create a barrier to accessing care. I don’t think it’s an efficient way to take on the high cost of care, and it creates a tiered system.” Like Dr. Frank, Dr. Sharfstein believes parity is a large part of the problem. When asked about the idea of ending networks and establishing uniform deductibles and reimbursement rates, Dr. Sharfstein replied: “It really depends. We would need fees to hit a sweet spot that supports care while controlling costs.”

One thing is clear: With the current paradigm, it is often difficult to access treatment, and the well-insured patients may bear a significant and disproportionate cost (if not the entire cost) for getting care. Many who need care do not get it, regardless of their insurance status. Our status quo for psychiatric care falls short and I don’t predict that psychiatrists will rush to join networks so long as the demand for psychiatrists is greater than the supply.

Might another financial model work better? We know the system is lacking and one option, as Dr. Frank suggests, is to find solutions within the current model. But perhaps the question should not be one of how to get more psychiatrists to join networks, but of how to rework the system without the assumption that networks are the only way. While Bob is pleased that his symptoms are getting better and he’s managed a way to tackle his own bills, it’s certainly time to explore new ways of delivering and reimbursing psychiatric care.

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle of Inpatient Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016), and has a private practice in Baltimore.

Bob has been coming to therapy for a few months now. Initially, we met every week, but as his depression lifted, he asked to space the sessions out to twice a month, even as he continues to struggle with many challenges in his life. The cost, he says, is prohibitive, and while Bob believed he had good commercial insurance coverage, he’s learned a few things about insurance and mental health care.

Bob was referred to me by his internist. He knew I did not participate in his insurance network, but his policy covers out-of-network care. He’d had a number of imaging studies and then knee surgery earlier in the year, so he believed he’d met his deductible. He learned that, while he’d met his in-network deductible, he’d had no out-of-network expenses and there was a separate, much higher deductible – one he was not likely to meet with outpatient psychiatric care. In fact, the full cost of his treatment was not being subtracted from the deductible he needed to meet, but rather he was getting credit for lower usual and customary evaluation and management and psychotherapy fees for each session. It became clear that it would be many months – if ever – before Bob could expect any reimbursement for his out-of-network visits.

What Bob didn’t know was that, had he decided to switch to an in-network psychiatrist, he might well have trouble finding one, since half of psychiatrists don’t participate with any health insurance plans. And if he did see an in-network psychiatrist, he would likely need to find a separate in-network social worker or psychologist for psychotherapy, because most in-network psychiatrists see patients for short medication-management appointments. While the insurance companies would give Bob a list of providers, those lists are not kept up to date and include psychiatrists who have died, moved, aren’t taking new patients, or who have retired. The insurance company clearly states on its voicemail that verification of services does not guarantee payment, and Bob was told that the only way he could be certain of the reimbursement would be to submit the claims and wait. He went into treatment fully understanding that he might get no help with the cost from his health insurance.

When I first started in private practice in the 1990s, I joined only one panel. An older colleague told me I was foolish to hesitate, and that soon the panels would fill and it would be too late; psychiatrists wouldn’t be able to get on to the panels and would be unable to attract patients. A few years later, that same psychiatrist withdrew from all the insurance panels he was on; working on their terms was not rewarding. This division of in-network and out-of-network care is crucial to managed care: They must attract panels of doctors who will work for lower rates or with stipulations on how the doctor practices in order to save money.

But managed care came with a price: An entire administration was created to oversee the regulation of treatment. With time, some aspects of care management have vanished; it has been years since I have been asked to fill out a treatment plan to justify a need for outpatient psychotherapy. In Bob’s case, it’s clear how they save money; since he will not reach his high deductible, he will bear the full cost of his psychotherapy. Other patients who cannot afford to go out of network may give up searching and decide to go without treatment – this is not always an easy service to negotiate when one is distressed and compromised. Half of people with serious psychiatric disorders are not in treatment, and barriers to getting care are certainly one reason why.

Many psychiatrists have discovered that they can maintain a practice without being on insurance panels, as managed care only works if there are enough players willing to toss the ball. As psychiatrists have shied away from these panels, insurers have raised their reimbursement rates, and in Maryland, Medicaid also has had to raise their rates. The struggle has become one of how to get enough mental health professionals, and psychiatrists in particular, to join insurance panels in what is a shortage field.

Maybe the question of how to get enough psychiatrists to participate with insurance panels is now the wrong question. Perhaps there are better ways to spend health care dollars than on the administration and management that come with limiting which doctors patients can see. The logistics of in-network versus out-of-network care are an expensive one, and create unconscionable scenarios in other fields. For example, such scenarios include ones in which a patient is brought in for emergency care to a facility where the doctors are not in network, or a patient has a procedure with an in-network surgeon but is unaware that the anesthesiologist or other members of the care team are not on the panel.

What if insurers controlled costs by setting a reasonable fee they would pay for services and paid any licensed physician for these services? Would market forces sort this out? Would fees then set to one which insurers would be willing to pay and physicians would be willing to accept? Or would those who are ill and impoverished be blocked from getting any care? What if we tried a whole new paradigm for psychiatric care?

Richard G. Frank, PhD, is a professor of health economics at Harvard. He specializes in mental health economics and is coauthor of the book “Better But Not Well: Mental Health Policy in the United States Since 1950” (Baltimore: Johns Hopkins University Press, 2006). Dr. Frank is a proponent of insurance panels.

“In the world we live in, we need to have panels; they are essential to controlling cost. They create a balance in terms of cost and utilization control in ways that protect patients, and they create a way for the insurance companies to bargain,” he said.

Dr. Frank noted that the concept that insurers should pay a set reasonable fee to any physician a patient wants to see has been tried. “It’s called ‘reference pricing,’ and when they did that with hip replacement surgery in California, it just hasn’t worked out. Patients ended up getting larger bills than they anticipated.

“The issues with psychiatry are different,” he continued. “There is a lot of bad behavior on the part of insurers and it’s an issue of parity. We shouldn’t let insurers differentially pay psychiatrists less. They have had an incentive to reduce the availability of mental health care and it’s bad for patients. It’s about lower payments to psychiatrists and the way those payments are currently structured drives patients out of care and defeats the purpose of insurance.”

Steven Sharfstein, MD, is the former CEO of Sheppard Pratt Health Systems, a past president of the American Psychiatric Association, and coauthor of several books on the economics of psychiatry. He refers to the current practice of credentialing network psychiatrists as a means of “rationing by supply.”

“The networks create a barrier to accessing care. I don’t think it’s an efficient way to take on the high cost of care, and it creates a tiered system.” Like Dr. Frank, Dr. Sharfstein believes parity is a large part of the problem. When asked about the idea of ending networks and establishing uniform deductibles and reimbursement rates, Dr. Sharfstein replied: “It really depends. We would need fees to hit a sweet spot that supports care while controlling costs.”

One thing is clear: With the current paradigm, it is often difficult to access treatment, and the well-insured patients may bear a significant and disproportionate cost (if not the entire cost) for getting care. Many who need care do not get it, regardless of their insurance status. Our status quo for psychiatric care falls short and I don’t predict that psychiatrists will rush to join networks so long as the demand for psychiatrists is greater than the supply.

Might another financial model work better? We know the system is lacking and one option, as Dr. Frank suggests, is to find solutions within the current model. But perhaps the question should not be one of how to get more psychiatrists to join networks, but of how to rework the system without the assumption that networks are the only way. While Bob is pleased that his symptoms are getting better and he’s managed a way to tackle his own bills, it’s certainly time to explore new ways of delivering and reimbursing psychiatric care.

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle of Inpatient Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016), and has a private practice in Baltimore.

If you take a nighttime stroll through the downtown district in any major U.S. city – and certainly in my hometown of Baltimore – you’ll find people sleeping on the streets. Advocates talk about “the homeless mentally ill,” and it’s estimated that a quarter of homeless persons suffer from psychiatric conditions. As psychiatrists, it’s good that we care about the homeless mentally ill. As human beings, shouldn’t we also care about the addicted and indigent homeless? In a country of wealth, it continues to be a disgrace that we have people who live in tent encampments, or who literally sleep on the ground in public places with all their belongings gathered around them.

With 25 contenders for the Democratic presidential nomination, Andrew Yang has caught my attention with his platform for a universal basic income (UBI), or “freedom dividend,” for all adults. Mr. Yang’s premise is a simple one: He’d like to give every person over the age of 18 a $1,000-a-month government-supplied income, funded by a new Value Added Tax (VAT), with no stipulations. I find the concept intriguing. It is the one suggestion that might make a drastic dent in extreme poverty in our country. In theory, every adult would have enough money to afford a place to sleep.

Paul Nestadt, MD, a psychiatrist at Johns Hopkins in Baltimore, agrees with the concept of a universal basic income. “The UBI seems like a humane and egalitarian way to eliminate starvation; it provides a ‘floor’ for poverty. It is a reasonable bare minimum, especially for our patients with serious mental illness who struggle to navigate the bureaucratic steeplechase required to have their basic needs met.” Dr. Nestadt believes that some of the other presidential candidates are supporting policies that would also accomplish this goal.

Marc Nozell/2.0 Generic (CC BY 2.0)

In the “Making Sense” podcast hosted by Sam Harris, “A conversation with Andrew Yang,” Mr. Yang made the point that a UBI is not a new concept – economists and politicians, including Richard Nixon, have supported the idea since the 1960s. A bill proposing a basic income passed in the House of Representatives in 1971 but did not pass in the Senate. In the podcast, Mr. Yang addresses the question of whether people are responsible for their own success, and whether, as Mr. Harris puts it, “it’s just simply wrong to hand out money to people.”

“It’s not as if the truck drivers are about to get dumber and lazier overnight,” Mr. Yang responded. “It’s just that their trucks are going to start driving themselves ... it has nothing to do with their character and work ethic.” He goes on to discuss how workers who lose jobs often leave the workforce and many go on disability.

“Right now, the country’s locked in a struggle between functioning and dysfunction, between reason and unreason, and scarcity and abundance, and scarcity is winning and that’s what we have to reverse through universal basic income; it’s our best way forward.”

If we are optimistic that our government could afford to provide everyone with both a UBI and a universal health plan, such as Medicare-for-all, I still wonder if there might be a societal downside. For self-motivated individuals, a sustenance allowance is unlikely to weaken a drive to achieve. But might there be people who decide they can live on this income, who choose instead to pursue leisure activities rather than pursue education and vocation? Mr. Harris asked Mr. Yang if we would be “subsidizing all the people in their mothers’ basement playing video games.”

Mr. Yang responded, “If you’re getting a thousand dollars a month, then you’re much more likely to get out of your parents’ basement and visit friends and find things to do that are somewhat more social and external-facing. A lot of the reason a lot of these men are retreating is because there’s no real economic security or path forward for them, and they feel much better served by going online and hanging out with their friends and making measurable progress in their gaming environment.”

I like to think that an automatic income would not crush a society’s motivation and productivity, and that money provided to people would fuel education, our economy, an ability to save, and entrepreneurial endeavors, but the truth is that we just don’t know. I would love to see such an experiment done as a large-scale pilot, with the ability to undo the experiment if it fails.

Andrew Yang remains a long shot as the Democratic presidential nominee. His platform, however, is enticing, and he takes on the imminent automation crisis in a way that no one else is actively addressing. His concepts include a degree of humanity that feels welcome when our current president is tweeting that those who are unhappy here should leave. While Mr. Yang is a bit lost in the fray, I do hope his innovative spirit gains some traction.
 

Dr. Miller is the coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016) and has a private practice in Baltimore.

If you take a nighttime stroll through the downtown district in any major U.S. city – and certainly in my hometown of Baltimore – you’ll find people sleeping on the streets. Advocates talk about “the homeless mentally ill,” and it’s estimated that a quarter of homeless persons suffer from psychiatric conditions. As psychiatrists, it’s good that we care about the homeless mentally ill. As human beings, shouldn’t we also care about the addicted and indigent homeless? In a country of wealth, it continues to be a disgrace that we have people who live in tent encampments, or who literally sleep on the ground in public places with all their belongings gathered around them.

With 25 contenders for the Democratic presidential nomination, Andrew Yang has caught my attention with his platform for a universal basic income (UBI), or “freedom dividend,” for all adults. Mr. Yang’s premise is a simple one: He’d like to give every person over the age of 18 a $1,000-a-month government-supplied income, funded by a new Value Added Tax (VAT), with no stipulations. I find the concept intriguing. It is the one suggestion that might make a drastic dent in extreme poverty in our country. In theory, every adult would have enough money to afford a place to sleep.

Paul Nestadt, MD, a psychiatrist at Johns Hopkins in Baltimore, agrees with the concept of a universal basic income. “The UBI seems like a humane and egalitarian way to eliminate starvation; it provides a ‘floor’ for poverty. It is a reasonable bare minimum, especially for our patients with serious mental illness who struggle to navigate the bureaucratic steeplechase required to have their basic needs met.” Dr. Nestadt believes that some of the other presidential candidates are supporting policies that would also accomplish this goal.

Marc Nozell/2.0 Generic (CC BY 2.0)

In the “Making Sense” podcast hosted by Sam Harris, “A conversation with Andrew Yang,” Mr. Yang made the point that a UBI is not a new concept – economists and politicians, including Richard Nixon, have supported the idea since the 1960s. A bill proposing a basic income passed in the House of Representatives in 1971 but did not pass in the Senate. In the podcast, Mr. Yang addresses the question of whether people are responsible for their own success, and whether, as Mr. Harris puts it, “it’s just simply wrong to hand out money to people.”

“It’s not as if the truck drivers are about to get dumber and lazier overnight,” Mr. Yang responded. “It’s just that their trucks are going to start driving themselves ... it has nothing to do with their character and work ethic.” He goes on to discuss how workers who lose jobs often leave the workforce and many go on disability.

“Right now, the country’s locked in a struggle between functioning and dysfunction, between reason and unreason, and scarcity and abundance, and scarcity is winning and that’s what we have to reverse through universal basic income; it’s our best way forward.”

If we are optimistic that our government could afford to provide everyone with both a UBI and a universal health plan, such as Medicare-for-all, I still wonder if there might be a societal downside. For self-motivated individuals, a sustenance allowance is unlikely to weaken a drive to achieve. But might there be people who decide they can live on this income, who choose instead to pursue leisure activities rather than pursue education and vocation? Mr. Harris asked Mr. Yang if we would be “subsidizing all the people in their mothers’ basement playing video games.”

Mr. Yang responded, “If you’re getting a thousand dollars a month, then you’re much more likely to get out of your parents’ basement and visit friends and find things to do that are somewhat more social and external-facing. A lot of the reason a lot of these men are retreating is because there’s no real economic security or path forward for them, and they feel much better served by going online and hanging out with their friends and making measurable progress in their gaming environment.”

I like to think that an automatic income would not crush a society’s motivation and productivity, and that money provided to people would fuel education, our economy, an ability to save, and entrepreneurial endeavors, but the truth is that we just don’t know. I would love to see such an experiment done as a large-scale pilot, with the ability to undo the experiment if it fails.

Andrew Yang remains a long shot as the Democratic presidential nominee. His platform, however, is enticing, and he takes on the imminent automation crisis in a way that no one else is actively addressing. His concepts include a degree of humanity that feels welcome when our current president is tweeting that those who are unhappy here should leave. While Mr. Yang is a bit lost in the fray, I do hope his innovative spirit gains some traction.
 

Dr. Miller is the coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016) and has a private practice in Baltimore.

If you take a nighttime stroll through the downtown district in any major U.S. city – and certainly in my hometown of Baltimore – you’ll find people sleeping on the streets. Advocates talk about “the homeless mentally ill,” and it’s estimated that a quarter of homeless persons suffer from psychiatric conditions. As psychiatrists, it’s good that we care about the homeless mentally ill. As human beings, shouldn’t we also care about the addicted and indigent homeless? In a country of wealth, it continues to be a disgrace that we have people who live in tent encampments, or who literally sleep on the ground in public places with all their belongings gathered around them.

With 25 contenders for the Democratic presidential nomination, Andrew Yang has caught my attention with his platform for a universal basic income (UBI), or “freedom dividend,” for all adults. Mr. Yang’s premise is a simple one: He’d like to give every person over the age of 18 a $1,000-a-month government-supplied income, funded by a new Value Added Tax (VAT), with no stipulations. I find the concept intriguing. It is the one suggestion that might make a drastic dent in extreme poverty in our country. In theory, every adult would have enough money to afford a place to sleep.

Paul Nestadt, MD, a psychiatrist at Johns Hopkins in Baltimore, agrees with the concept of a universal basic income. “The UBI seems like a humane and egalitarian way to eliminate starvation; it provides a ‘floor’ for poverty. It is a reasonable bare minimum, especially for our patients with serious mental illness who struggle to navigate the bureaucratic steeplechase required to have their basic needs met.” Dr. Nestadt believes that some of the other presidential candidates are supporting policies that would also accomplish this goal.

Marc Nozell/2.0 Generic (CC BY 2.0)

In the “Making Sense” podcast hosted by Sam Harris, “A conversation with Andrew Yang,” Mr. Yang made the point that a UBI is not a new concept – economists and politicians, including Richard Nixon, have supported the idea since the 1960s. A bill proposing a basic income passed in the House of Representatives in 1971 but did not pass in the Senate. In the podcast, Mr. Yang addresses the question of whether people are responsible for their own success, and whether, as Mr. Harris puts it, “it’s just simply wrong to hand out money to people.”

“It’s not as if the truck drivers are about to get dumber and lazier overnight,” Mr. Yang responded. “It’s just that their trucks are going to start driving themselves ... it has nothing to do with their character and work ethic.” He goes on to discuss how workers who lose jobs often leave the workforce and many go on disability.

“Right now, the country’s locked in a struggle between functioning and dysfunction, between reason and unreason, and scarcity and abundance, and scarcity is winning and that’s what we have to reverse through universal basic income; it’s our best way forward.”

If we are optimistic that our government could afford to provide everyone with both a UBI and a universal health plan, such as Medicare-for-all, I still wonder if there might be a societal downside. For self-motivated individuals, a sustenance allowance is unlikely to weaken a drive to achieve. But might there be people who decide they can live on this income, who choose instead to pursue leisure activities rather than pursue education and vocation? Mr. Harris asked Mr. Yang if we would be “subsidizing all the people in their mothers’ basement playing video games.”

Mr. Yang responded, “If you’re getting a thousand dollars a month, then you’re much more likely to get out of your parents’ basement and visit friends and find things to do that are somewhat more social and external-facing. A lot of the reason a lot of these men are retreating is because there’s no real economic security or path forward for them, and they feel much better served by going online and hanging out with their friends and making measurable progress in their gaming environment.”

I like to think that an automatic income would not crush a society’s motivation and productivity, and that money provided to people would fuel education, our economy, an ability to save, and entrepreneurial endeavors, but the truth is that we just don’t know. I would love to see such an experiment done as a large-scale pilot, with the ability to undo the experiment if it fails.

Andrew Yang remains a long shot as the Democratic presidential nominee. His platform, however, is enticing, and he takes on the imminent automation crisis in a way that no one else is actively addressing. His concepts include a degree of humanity that feels welcome when our current president is tweeting that those who are unhappy here should leave. While Mr. Yang is a bit lost in the fray, I do hope his innovative spirit gains some traction.
 

Dr. Miller is the coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016) and has a private practice in Baltimore.

It was an unthinkable crime; on July 20, 2012, a 24-year-old neuroscience graduate student* walked into a movie theatre in Aurora, Colo., and began shooting people he had never before seen. Twelve people died and 70 were wounded in this calculated and intricately planned massacre that challenged everything we know about the intersection of mental illness and evil.

So much has been written about mass shooters as we’ve struggled to understand what motivates someone to kill strangers in a public place. The hope is that if we can understand it, then we can prevent it. The topic has been one of great interest to me because it gets quickly linked to advocacy for involuntary psychiatric care: Half of mass murderers suffer from psychiatric disorders and if we could force them to get treatment, then we could prevent these horrific events.

Courtesy Wikimedia Commons/Algr/Creative Commons License

In this case, the perpetrator had been treated by a therapist and two psychiatrists at his university counseling center in the semester before the shooting. There were video recordings of the defendant in his cell, a correctional psychiatrist in the local jail; psychiatric records from an admission to Denver Health Medical Center and two admissions to the Colorado Health Institute at Pueblo (a secure, forensic setting); and neuropsychological testing done by psychologists hired for the case. In all, there was a lot of mental health data, and I’m not aware of any other book that has been written by a psychiatrist about a criminal case where the author testified in the case.

Let me start by saying that the book is well written, very readable, and fascinating. I’d followed parts of the case in the news and had even watched some of the trial being live-streamed, so not all of the information was new, but Dr. Reid has put together the many facts of a perplexing case together in a cohesive way. There’s no literary descriptions or flowery writing; Dr. Reid is a focused writer. He also does a good job of explaining the specifics of Colorado state law to the forensic aspects of the case. In the end, there were nuances of how the shooter came to be found both competent and sane but was spared the death penalty by a single vote. Overall, I found the book haunting, and it would have been a more comfortable read if it were fiction. There was something terribly disconcerting about following along this miserable journey, all the while knowing that the killer ultimately would destroy so many lives and then watching his disconnected existence after the massacre.

As a general adult psychiatrist, I wanted to learn something very specific from this book: What is the recipe for creating a mass murderer and what are the warning signs a psychiatrist should catch? I would like my career to be free of patients who kill. The Aurora shooter’s family life sounded fairly pedestrian. His parents are professionals; there was a boy and a girl in an intact family with attentive parents, and no findings of abuse, torture, neglect, bullying, or anything out of the ordinary.

As a child, the shooter was noted for his kindness, and he was particularly caring toward his younger sister. As he grew older, reports about his personality were conflicting: Some saw him as awkward, and later even as odd, while others described him as normal, especially within a cohort of studious kids. He played on sports teams, was an excellent student, liked nonviolent video games, and while he was not outgoing, he always had some friends, though he shunned them during the semester before the shooting. He was not comfortable with women, but he had one girlfriend in graduate school, and when that relationship broke up, he texted with another classmate about how “hot” she was and that they went hiking together. The breakup may have contributed to the shooter’s unraveling, but if it did, Dr. Reid did not present this as the precipitant, and many young men are awkward with women – and endure breakups and rejection.

While the media said the shooter failed out of school, this was not the case. He did well in his classes but chose not to study for an important oral exam while he devoted his time to gathering weapons for his mission to kill, planning out the details, learning to use firearms, and rigging up a complex explosive system around his apartment. When he failed the oral exam, he was told he could study and retake it in a few weeks. He chose, instead, to withdraw from graduate school.

What stood out for me was that this young man talked about thoughts of killing people. He did so to the point of worrying his psychiatrist: She called in a second psychiatrist for a consultation, alerted the university’s threat assessment team, contacted an out-of-state parent, and considered admitting him on an involuntary hold. While many patients say they might hurt someone if provoked or threatened, few discuss thoughts of killing indiscriminately. But when people do talk about killing, we do our best to flush out their intentions, whether it is a fantasy or a plan, if they’ve been violent before. This shooter had no history of violence, and he hid from the psychiatrist the fact that he was acquiring weapons and actually planning a massacre. His psychiatrist diagnosed him with social anxiety, obsessive-compulsive disorder, and possible schizotypal personality disorder. He was prescribed an antidepressant, and later offered an antipsychotic, which he refused.

Three of the four psychiatrists who evaluated the defendant for the legal proceedings made a diagnosis of schizoaffective disorder. (The fifth psychiatrist for the prosecution never examined the defendant.) Dr. Reid made a diagnosis of schizotypal personality disorder. Everyone agreed that the shooter had a mental illness that influenced his actions. When it came to ascertaining the defendant’s mental state at the time of the crime, there was a glitch: The first psychiatrist for the defense examined the defendant only once, days after the shooting, and not again until 3 years later, right before the trial. His exam was limited: The defense attorney was present in the room, and he had instructed the psychiatrist not to ask about the shooting. The attorney interrupted the interview twice, and it’s not the usual practice to place these conditions on a forensic evaluation. After that exam, there was some misunderstanding about who was in charge of the treatment, and the defendant refused the services of the jail psychiatrist. It was not until 4 months later when the inmate became dehydrated, delirious, and psychotic that he finally was evaluated and treated. Despite the abundance of psychiatric information available, no direct and complete assessment was made by a psychiatrist immediately before the shooting, or in the months right after.

When we try to understand what motivates someone to commit such a heinous act, we look for psychosis. If the person suffers from paranoid delusions and believes his behavior is in self-defense, the behavior becomes understandable and justifiable. Even if it’s less organized, if it is the clear result of a psychotic thought process, we often attribute the behavior to illness. Usually, people with psychosis are too disorganized to enact complex plans, to acquire and learn to use ammunition, to plot out when and where there will be potential victims, and to plot out this degree of planning.

This shooter had an odd belief that if he killed people, he would attain “human capital.” Their deaths might fortify him, increase his value and decrease his suffering, and thereby prevent him from dying by suicide. Dr. Reid talks about whether it’s a delusion, an overvalued idea, or just an unusual belief. The shooter was aware that others don’t agree with this, that they would see it as wrong and criminal, and he thought there was only a 50% chance that it would work. If this were a delusion, it was not one we typically see, nor was it accompanied by more usual perceptual phenomena. Ultimately, there was no consensus on whether the patient was psychotic at the time of the shooting. On antipsychotic medication, he continued to believe that if he killed people that he would attain their human capital. In his book, Dr. Reid concluded that he remained dangerous.

Because the shooter told the university health center psychiatrist that he did not want to be locked up, she considered involuntary hospitalization, but she did not believe he would meet criteria for commitment. I saw nothing that indicated whether he was offered voluntary inpatient care with an explanation that hospital treatment is not the same as being locked up and might help alleviate his suffering. We don’t know if he could have been persuaded to enter the hospital willingly, but I suspect that this would have been difficult to justify to an insurer. There’s nothing to indicate that a hospitalization would have prevented this massacre.

From my perspective, I concluded that if individuals say they are thinking about killing strangers, they may be at risk of violence. This is a much smaller group of people to target for intervention than everyone with mental illness or everyone who is odd. This particular shooter appears to suffer from some type of mental derangement that does not fit neatly into our current psychiatric nomenclature or respond to our current treatments, and thoughtful psychiatric intervention – which he had – could not prevent his actions. It seems the only thing that would have changed this outcome is if someone had discovered his arsenal before July 20, 2012. 

*Please note: The shooter’s name is intentionally omitted from my review. 

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016).

It was an unthinkable crime; on July 20, 2012, a 24-year-old neuroscience graduate student* walked into a movie theatre in Aurora, Colo., and began shooting people he had never before seen. Twelve people died and 70 were wounded in this calculated and intricately planned massacre that challenged everything we know about the intersection of mental illness and evil.

So much has been written about mass shooters as we’ve struggled to understand what motivates someone to kill strangers in a public place. The hope is that if we can understand it, then we can prevent it. The topic has been one of great interest to me because it gets quickly linked to advocacy for involuntary psychiatric care: Half of mass murderers suffer from psychiatric disorders and if we could force them to get treatment, then we could prevent these horrific events.

Courtesy Wikimedia Commons/Algr/Creative Commons License

In this case, the perpetrator had been treated by a therapist and two psychiatrists at his university counseling center in the semester before the shooting. There were video recordings of the defendant in his cell, a correctional psychiatrist in the local jail; psychiatric records from an admission to Denver Health Medical Center and two admissions to the Colorado Health Institute at Pueblo (a secure, forensic setting); and neuropsychological testing done by psychologists hired for the case. In all, there was a lot of mental health data, and I’m not aware of any other book that has been written by a psychiatrist about a criminal case where the author testified in the case.

Let me start by saying that the book is well written, very readable, and fascinating. I’d followed parts of the case in the news and had even watched some of the trial being live-streamed, so not all of the information was new, but Dr. Reid has put together the many facts of a perplexing case together in a cohesive way. There’s no literary descriptions or flowery writing; Dr. Reid is a focused writer. He also does a good job of explaining the specifics of Colorado state law to the forensic aspects of the case. In the end, there were nuances of how the shooter came to be found both competent and sane but was spared the death penalty by a single vote. Overall, I found the book haunting, and it would have been a more comfortable read if it were fiction. There was something terribly disconcerting about following along this miserable journey, all the while knowing that the killer ultimately would destroy so many lives and then watching his disconnected existence after the massacre.

As a general adult psychiatrist, I wanted to learn something very specific from this book: What is the recipe for creating a mass murderer and what are the warning signs a psychiatrist should catch? I would like my career to be free of patients who kill. The Aurora shooter’s family life sounded fairly pedestrian. His parents are professionals; there was a boy and a girl in an intact family with attentive parents, and no findings of abuse, torture, neglect, bullying, or anything out of the ordinary.

As a child, the shooter was noted for his kindness, and he was particularly caring toward his younger sister. As he grew older, reports about his personality were conflicting: Some saw him as awkward, and later even as odd, while others described him as normal, especially within a cohort of studious kids. He played on sports teams, was an excellent student, liked nonviolent video games, and while he was not outgoing, he always had some friends, though he shunned them during the semester before the shooting. He was not comfortable with women, but he had one girlfriend in graduate school, and when that relationship broke up, he texted with another classmate about how “hot” she was and that they went hiking together. The breakup may have contributed to the shooter’s unraveling, but if it did, Dr. Reid did not present this as the precipitant, and many young men are awkward with women – and endure breakups and rejection.

While the media said the shooter failed out of school, this was not the case. He did well in his classes but chose not to study for an important oral exam while he devoted his time to gathering weapons for his mission to kill, planning out the details, learning to use firearms, and rigging up a complex explosive system around his apartment. When he failed the oral exam, he was told he could study and retake it in a few weeks. He chose, instead, to withdraw from graduate school.

What stood out for me was that this young man talked about thoughts of killing people. He did so to the point of worrying his psychiatrist: She called in a second psychiatrist for a consultation, alerted the university’s threat assessment team, contacted an out-of-state parent, and considered admitting him on an involuntary hold. While many patients say they might hurt someone if provoked or threatened, few discuss thoughts of killing indiscriminately. But when people do talk about killing, we do our best to flush out their intentions, whether it is a fantasy or a plan, if they’ve been violent before. This shooter had no history of violence, and he hid from the psychiatrist the fact that he was acquiring weapons and actually planning a massacre. His psychiatrist diagnosed him with social anxiety, obsessive-compulsive disorder, and possible schizotypal personality disorder. He was prescribed an antidepressant, and later offered an antipsychotic, which he refused.

Three of the four psychiatrists who evaluated the defendant for the legal proceedings made a diagnosis of schizoaffective disorder. (The fifth psychiatrist for the prosecution never examined the defendant.) Dr. Reid made a diagnosis of schizotypal personality disorder. Everyone agreed that the shooter had a mental illness that influenced his actions. When it came to ascertaining the defendant’s mental state at the time of the crime, there was a glitch: The first psychiatrist for the defense examined the defendant only once, days after the shooting, and not again until 3 years later, right before the trial. His exam was limited: The defense attorney was present in the room, and he had instructed the psychiatrist not to ask about the shooting. The attorney interrupted the interview twice, and it’s not the usual practice to place these conditions on a forensic evaluation. After that exam, there was some misunderstanding about who was in charge of the treatment, and the defendant refused the services of the jail psychiatrist. It was not until 4 months later when the inmate became dehydrated, delirious, and psychotic that he finally was evaluated and treated. Despite the abundance of psychiatric information available, no direct and complete assessment was made by a psychiatrist immediately before the shooting, or in the months right after.

When we try to understand what motivates someone to commit such a heinous act, we look for psychosis. If the person suffers from paranoid delusions and believes his behavior is in self-defense, the behavior becomes understandable and justifiable. Even if it’s less organized, if it is the clear result of a psychotic thought process, we often attribute the behavior to illness. Usually, people with psychosis are too disorganized to enact complex plans, to acquire and learn to use ammunition, to plot out when and where there will be potential victims, and to plot out this degree of planning.

This shooter had an odd belief that if he killed people, he would attain “human capital.” Their deaths might fortify him, increase his value and decrease his suffering, and thereby prevent him from dying by suicide. Dr. Reid talks about whether it’s a delusion, an overvalued idea, or just an unusual belief. The shooter was aware that others don’t agree with this, that they would see it as wrong and criminal, and he thought there was only a 50% chance that it would work. If this were a delusion, it was not one we typically see, nor was it accompanied by more usual perceptual phenomena. Ultimately, there was no consensus on whether the patient was psychotic at the time of the shooting. On antipsychotic medication, he continued to believe that if he killed people that he would attain their human capital. In his book, Dr. Reid concluded that he remained dangerous.

Because the shooter told the university health center psychiatrist that he did not want to be locked up, she considered involuntary hospitalization, but she did not believe he would meet criteria for commitment. I saw nothing that indicated whether he was offered voluntary inpatient care with an explanation that hospital treatment is not the same as being locked up and might help alleviate his suffering. We don’t know if he could have been persuaded to enter the hospital willingly, but I suspect that this would have been difficult to justify to an insurer. There’s nothing to indicate that a hospitalization would have prevented this massacre.

From my perspective, I concluded that if individuals say they are thinking about killing strangers, they may be at risk of violence. This is a much smaller group of people to target for intervention than everyone with mental illness or everyone who is odd. This particular shooter appears to suffer from some type of mental derangement that does not fit neatly into our current psychiatric nomenclature or respond to our current treatments, and thoughtful psychiatric intervention – which he had – could not prevent his actions. It seems the only thing that would have changed this outcome is if someone had discovered his arsenal before July 20, 2012. 

*Please note: The shooter’s name is intentionally omitted from my review. 

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016).

It was an unthinkable crime; on July 20, 2012, a 24-year-old neuroscience graduate student* walked into a movie theatre in Aurora, Colo., and began shooting people he had never before seen. Twelve people died and 70 were wounded in this calculated and intricately planned massacre that challenged everything we know about the intersection of mental illness and evil.

So much has been written about mass shooters as we’ve struggled to understand what motivates someone to kill strangers in a public place. The hope is that if we can understand it, then we can prevent it. The topic has been one of great interest to me because it gets quickly linked to advocacy for involuntary psychiatric care: Half of mass murderers suffer from psychiatric disorders and if we could force them to get treatment, then we could prevent these horrific events.

Courtesy Wikimedia Commons/Algr/Creative Commons License

In this case, the perpetrator had been treated by a therapist and two psychiatrists at his university counseling center in the semester before the shooting. There were video recordings of the defendant in his cell, a correctional psychiatrist in the local jail; psychiatric records from an admission to Denver Health Medical Center and two admissions to the Colorado Health Institute at Pueblo (a secure, forensic setting); and neuropsychological testing done by psychologists hired for the case. In all, there was a lot of mental health data, and I’m not aware of any other book that has been written by a psychiatrist about a criminal case where the author testified in the case.

Let me start by saying that the book is well written, very readable, and fascinating. I’d followed parts of the case in the news and had even watched some of the trial being live-streamed, so not all of the information was new, but Dr. Reid has put together the many facts of a perplexing case together in a cohesive way. There’s no literary descriptions or flowery writing; Dr. Reid is a focused writer. He also does a good job of explaining the specifics of Colorado state law to the forensic aspects of the case. In the end, there were nuances of how the shooter came to be found both competent and sane but was spared the death penalty by a single vote. Overall, I found the book haunting, and it would have been a more comfortable read if it were fiction. There was something terribly disconcerting about following along this miserable journey, all the while knowing that the killer ultimately would destroy so many lives and then watching his disconnected existence after the massacre.

As a general adult psychiatrist, I wanted to learn something very specific from this book: What is the recipe for creating a mass murderer and what are the warning signs a psychiatrist should catch? I would like my career to be free of patients who kill. The Aurora shooter’s family life sounded fairly pedestrian. His parents are professionals; there was a boy and a girl in an intact family with attentive parents, and no findings of abuse, torture, neglect, bullying, or anything out of the ordinary.

As a child, the shooter was noted for his kindness, and he was particularly caring toward his younger sister. As he grew older, reports about his personality were conflicting: Some saw him as awkward, and later even as odd, while others described him as normal, especially within a cohort of studious kids. He played on sports teams, was an excellent student, liked nonviolent video games, and while he was not outgoing, he always had some friends, though he shunned them during the semester before the shooting. He was not comfortable with women, but he had one girlfriend in graduate school, and when that relationship broke up, he texted with another classmate about how “hot” she was and that they went hiking together. The breakup may have contributed to the shooter’s unraveling, but if it did, Dr. Reid did not present this as the precipitant, and many young men are awkward with women – and endure breakups and rejection.

While the media said the shooter failed out of school, this was not the case. He did well in his classes but chose not to study for an important oral exam while he devoted his time to gathering weapons for his mission to kill, planning out the details, learning to use firearms, and rigging up a complex explosive system around his apartment. When he failed the oral exam, he was told he could study and retake it in a few weeks. He chose, instead, to withdraw from graduate school.

What stood out for me was that this young man talked about thoughts of killing people. He did so to the point of worrying his psychiatrist: She called in a second psychiatrist for a consultation, alerted the university’s threat assessment team, contacted an out-of-state parent, and considered admitting him on an involuntary hold. While many patients say they might hurt someone if provoked or threatened, few discuss thoughts of killing indiscriminately. But when people do talk about killing, we do our best to flush out their intentions, whether it is a fantasy or a plan, if they’ve been violent before. This shooter had no history of violence, and he hid from the psychiatrist the fact that he was acquiring weapons and actually planning a massacre. His psychiatrist diagnosed him with social anxiety, obsessive-compulsive disorder, and possible schizotypal personality disorder. He was prescribed an antidepressant, and later offered an antipsychotic, which he refused.

Three of the four psychiatrists who evaluated the defendant for the legal proceedings made a diagnosis of schizoaffective disorder. (The fifth psychiatrist for the prosecution never examined the defendant.) Dr. Reid made a diagnosis of schizotypal personality disorder. Everyone agreed that the shooter had a mental illness that influenced his actions. When it came to ascertaining the defendant’s mental state at the time of the crime, there was a glitch: The first psychiatrist for the defense examined the defendant only once, days after the shooting, and not again until 3 years later, right before the trial. His exam was limited: The defense attorney was present in the room, and he had instructed the psychiatrist not to ask about the shooting. The attorney interrupted the interview twice, and it’s not the usual practice to place these conditions on a forensic evaluation. After that exam, there was some misunderstanding about who was in charge of the treatment, and the defendant refused the services of the jail psychiatrist. It was not until 4 months later when the inmate became dehydrated, delirious, and psychotic that he finally was evaluated and treated. Despite the abundance of psychiatric information available, no direct and complete assessment was made by a psychiatrist immediately before the shooting, or in the months right after.

When we try to understand what motivates someone to commit such a heinous act, we look for psychosis. If the person suffers from paranoid delusions and believes his behavior is in self-defense, the behavior becomes understandable and justifiable. Even if it’s less organized, if it is the clear result of a psychotic thought process, we often attribute the behavior to illness. Usually, people with psychosis are too disorganized to enact complex plans, to acquire and learn to use ammunition, to plot out when and where there will be potential victims, and to plot out this degree of planning.

This shooter had an odd belief that if he killed people, he would attain “human capital.” Their deaths might fortify him, increase his value and decrease his suffering, and thereby prevent him from dying by suicide. Dr. Reid talks about whether it’s a delusion, an overvalued idea, or just an unusual belief. The shooter was aware that others don’t agree with this, that they would see it as wrong and criminal, and he thought there was only a 50% chance that it would work. If this were a delusion, it was not one we typically see, nor was it accompanied by more usual perceptual phenomena. Ultimately, there was no consensus on whether the patient was psychotic at the time of the shooting. On antipsychotic medication, he continued to believe that if he killed people that he would attain their human capital. In his book, Dr. Reid concluded that he remained dangerous.

Because the shooter told the university health center psychiatrist that he did not want to be locked up, she considered involuntary hospitalization, but she did not believe he would meet criteria for commitment. I saw nothing that indicated whether he was offered voluntary inpatient care with an explanation that hospital treatment is not the same as being locked up and might help alleviate his suffering. We don’t know if he could have been persuaded to enter the hospital willingly, but I suspect that this would have been difficult to justify to an insurer. There’s nothing to indicate that a hospitalization would have prevented this massacre.

From my perspective, I concluded that if individuals say they are thinking about killing strangers, they may be at risk of violence. This is a much smaller group of people to target for intervention than everyone with mental illness or everyone who is odd. This particular shooter appears to suffer from some type of mental derangement that does not fit neatly into our current psychiatric nomenclature or respond to our current treatments, and thoughtful psychiatric intervention – which he had – could not prevent his actions. It seems the only thing that would have changed this outcome is if someone had discovered his arsenal before July 20, 2012. 

*Please note: The shooter’s name is intentionally omitted from my review. 

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016).

SAN FRANCISCO – A number of years ago, Anne Hanson, Steve Daviss, and I worked together on a psychiatry podcast called “My Three Shrinks.” In the course of making the podcast, Dr. Daviss suggested the three of us should take an improv class together – he felt it would help us blend together better as we interacted to create these dialogues.

We met on Sunday afternoons around one of our dining room tables, often with chili and beer, sometimes with guest psychiatrists, and over the course of a few years, we produced 70 episodes. But we never did take that improv class together.

Steve conveyed that in improv, it’s bad to say, “No, but ...” and instead, one should say, “Yes, and ...” to build upon a theme while working in concert with others. With this limited background, I decided that at this year’s American Psychiatric Association meeting in San Francisco I would report on a session called “You Are Human: Addressing Burnout Through Improv,” organized by Tristan Gorrindo, MD, the director of education and deputy medical director for the APA, and Ashley Whitehurst, a program manager in continuing medical education and faculty at the Second City Training Center, a Chicago-based comedy institution. The session was held on Tuesday morning and was attended by psychiatrists of all training levels. Name badges revealed that attendees were from across the United States and from Canada, Mexico, and one psychiatrist from South Africa.

Before I write about the session on using improv to address physician burnout, I’d like to back up a day, as this was not the first session I found at APA where people were acting out! On Monday, I had gone to a workshop called “Inside OCD: I Am Not My Illness.” I went with the hope of learning something about obsessive-compulsive disorder that I could use to help my patients who suffer from this disorder, with no intention of writing about the session. I was running quite late and chose the session based solely on the title. I stumbled into a rather unusual venue: Patients with OCD were putting on a performance where they discussed how it was to live with the symptoms of this disabling illness, stretched into a humorous storytelling adventure.

The performance group, a joint venture of the Center for Arts in Medicine at the University of Florida in partnership with University of Florida Center for OCD, Anxiety, & Related Disorders consisted of patients who came together in a 10-week course with an acting coach, a resident psychiatrist who participated with the group, and the oversight of their attending psychiatrist, Carol Mathews, MD, to create this collaborative and moving theatrical performance. The group performed, then talked about how this endeavor had helped them to share their stories, to grow in their self-acceptance and self-confidence, and to enjoy a sense of community, and escape from shame and loneliness.

On Monday, I went from the OCD theater to a session called “Unscripting: Using Improvisational Theatre to Move Beyond Personal Limitations.” This workshop was led by Jeffrey Katzman, MD, a psychiatrist who practices in Albuquerque, N.M., and coauthor of “Life Unscripted: Using Improv Principles to Get Unstuck, Boost Confidence, and Transform Your Life.” Dr. Katzman referenced how improv requires the participants to collaborate and respond to one another in ways that are not unlike what occurs in psychotherapy.

“It’s about two people listening to each other, reacting to each other, and ultimately regulating one another.”

A second speaker, Peter Felsman, PhD, LMSW, presented his doctoral dissertation work looking at how improv classes might impact teens with anxiety disorders.

It was at this session that I had my first experiences actually doing some improv exercises. “Improv involves increasing your uncertainty tolerance,” Dr. Katzman noted. “The available scripts are much broader than what you are used to, and they increase the sense of autonomy.” Participants were challenged to work at mirroring the actions of a partner, of switching who was leading in these exercises, and of telling stories where we built upon what the last person gave to the tale by adding unpredictable paths of plot development.

The Tuesday morning session was longer; it lasted from 8 a.m. to 11 a.m. I arrived early, and the first name tag I saw was that of Steven Reidbord, MD, a psychiatrist in San Francisco whom I had never met, but with whom I had interacted many times over the years as we both have had psychiatry blogs. I was delighted as I started the session. Dr. Gorrindo started the symposium by defining physician burnout and discussing how our current system fuels burnout. He discussed his own interest in improv and its use to foster more creative, flexible, and collaborative responses.

Ashley Whitehurst then led the participants in a series of exercises. We walked around the room taking unscripted turns yelling out “I am a star” while the rest of the participants clustered around to frame each individual star! We took partners and discussed a toy each of us had longed for and never gotten in childhood, then created a fictional toy as conglomerate of those toys never received. This light exercise included conversations about the sadness of the toys longed for and the disappointments we’d suffered. One psychiatrist felt gratitude: She had received most of the toys she’d wanted. There were others who’d wanted a real pony or a real typewriter, only to be gifted with disappointing plastic versions. One gentleman longed for a sibling who had died before he had even been born; there were no toys for this space.

Our circle conversations moved into tales we created by interrupting one another with our associations about what we loved and hated; there was the annoyance of having sand in your underwear and superheros who deliver ice cream. We all talked about what it involved to let go of our own agendas and fold into what was going on in the moment, to sway with a plot that changed as soon as it was formed, to function with rules so different from what we were used to. Participants talked about feeling vulnerable, open, playful, and connected. We discussed how improv might be useful in teaching trainees.

“This was interesting and different,” said Sergio Lobato, MD, a psychiatrist from Tijuana, Mexico, who retired after more than 30 years of working in a government hospital. “I saw 20 to 30 patients a day, and there was some burnout. I’m here at the meeting and trying to learn things to help my daughter, who is in her third year of psychiatry training.”

Ms. Whitehurst, our improv instructor, has done many of these workshops with people of all ages and with other groups of physicians. “When people sign up for improv classes, they usually have some idea what they are getting into. With doctors at a conference, it takes just a little longer for them to let their guard down. Improv is an art form and a way to create, it’s a great equalizer and I’ve noticed an evolution in myself as it has changed how I interact. ”

Veronica Samet, a PGY-4 resident from Emory University, Atlanta, added: “In psychiatry, we are taught to leave space in the room for the other person. You get used to compressing yourself into something neutral and it’s hard not to bring that state home. This experience was revitalizing!”

I was delighted to find a friend when I walked into the morning symposium and by the time I left, I felt like I’d made a roomful of friends. We’d played games and I was completely consumed by the tasks at hand. We talked about how each game made us feel, and in some ways this was not all that far off from work as a psychiatrist – the humor and fun were on the surface, but ... or rather, “ ... yes, and” the stories that went along with what we did made for a moment of connection in a whole new way.

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice in Baltimore.

SAN FRANCISCO – A number of years ago, Anne Hanson, Steve Daviss, and I worked together on a psychiatry podcast called “My Three Shrinks.” In the course of making the podcast, Dr. Daviss suggested the three of us should take an improv class together – he felt it would help us blend together better as we interacted to create these dialogues.

We met on Sunday afternoons around one of our dining room tables, often with chili and beer, sometimes with guest psychiatrists, and over the course of a few years, we produced 70 episodes. But we never did take that improv class together.

Steve conveyed that in improv, it’s bad to say, “No, but ...” and instead, one should say, “Yes, and ...” to build upon a theme while working in concert with others. With this limited background, I decided that at this year’s American Psychiatric Association meeting in San Francisco I would report on a session called “You Are Human: Addressing Burnout Through Improv,” organized by Tristan Gorrindo, MD, the director of education and deputy medical director for the APA, and Ashley Whitehurst, a program manager in continuing medical education and faculty at the Second City Training Center, a Chicago-based comedy institution. The session was held on Tuesday morning and was attended by psychiatrists of all training levels. Name badges revealed that attendees were from across the United States and from Canada, Mexico, and one psychiatrist from South Africa.

Before I write about the session on using improv to address physician burnout, I’d like to back up a day, as this was not the first session I found at APA where people were acting out! On Monday, I had gone to a workshop called “Inside OCD: I Am Not My Illness.” I went with the hope of learning something about obsessive-compulsive disorder that I could use to help my patients who suffer from this disorder, with no intention of writing about the session. I was running quite late and chose the session based solely on the title. I stumbled into a rather unusual venue: Patients with OCD were putting on a performance where they discussed how it was to live with the symptoms of this disabling illness, stretched into a humorous storytelling adventure.

The performance group, a joint venture of the Center for Arts in Medicine at the University of Florida in partnership with University of Florida Center for OCD, Anxiety, & Related Disorders consisted of patients who came together in a 10-week course with an acting coach, a resident psychiatrist who participated with the group, and the oversight of their attending psychiatrist, Carol Mathews, MD, to create this collaborative and moving theatrical performance. The group performed, then talked about how this endeavor had helped them to share their stories, to grow in their self-acceptance and self-confidence, and to enjoy a sense of community, and escape from shame and loneliness.

On Monday, I went from the OCD theater to a session called “Unscripting: Using Improvisational Theatre to Move Beyond Personal Limitations.” This workshop was led by Jeffrey Katzman, MD, a psychiatrist who practices in Albuquerque, N.M., and coauthor of “Life Unscripted: Using Improv Principles to Get Unstuck, Boost Confidence, and Transform Your Life.” Dr. Katzman referenced how improv requires the participants to collaborate and respond to one another in ways that are not unlike what occurs in psychotherapy.

“It’s about two people listening to each other, reacting to each other, and ultimately regulating one another.”

A second speaker, Peter Felsman, PhD, LMSW, presented his doctoral dissertation work looking at how improv classes might impact teens with anxiety disorders.

It was at this session that I had my first experiences actually doing some improv exercises. “Improv involves increasing your uncertainty tolerance,” Dr. Katzman noted. “The available scripts are much broader than what you are used to, and they increase the sense of autonomy.” Participants were challenged to work at mirroring the actions of a partner, of switching who was leading in these exercises, and of telling stories where we built upon what the last person gave to the tale by adding unpredictable paths of plot development.

The Tuesday morning session was longer; it lasted from 8 a.m. to 11 a.m. I arrived early, and the first name tag I saw was that of Steven Reidbord, MD, a psychiatrist in San Francisco whom I had never met, but with whom I had interacted many times over the years as we both have had psychiatry blogs. I was delighted as I started the session. Dr. Gorrindo started the symposium by defining physician burnout and discussing how our current system fuels burnout. He discussed his own interest in improv and its use to foster more creative, flexible, and collaborative responses.

Ashley Whitehurst then led the participants in a series of exercises. We walked around the room taking unscripted turns yelling out “I am a star” while the rest of the participants clustered around to frame each individual star! We took partners and discussed a toy each of us had longed for and never gotten in childhood, then created a fictional toy as conglomerate of those toys never received. This light exercise included conversations about the sadness of the toys longed for and the disappointments we’d suffered. One psychiatrist felt gratitude: She had received most of the toys she’d wanted. There were others who’d wanted a real pony or a real typewriter, only to be gifted with disappointing plastic versions. One gentleman longed for a sibling who had died before he had even been born; there were no toys for this space.

Our circle conversations moved into tales we created by interrupting one another with our associations about what we loved and hated; there was the annoyance of having sand in your underwear and superheros who deliver ice cream. We all talked about what it involved to let go of our own agendas and fold into what was going on in the moment, to sway with a plot that changed as soon as it was formed, to function with rules so different from what we were used to. Participants talked about feeling vulnerable, open, playful, and connected. We discussed how improv might be useful in teaching trainees.

“This was interesting and different,” said Sergio Lobato, MD, a psychiatrist from Tijuana, Mexico, who retired after more than 30 years of working in a government hospital. “I saw 20 to 30 patients a day, and there was some burnout. I’m here at the meeting and trying to learn things to help my daughter, who is in her third year of psychiatry training.”

Ms. Whitehurst, our improv instructor, has done many of these workshops with people of all ages and with other groups of physicians. “When people sign up for improv classes, they usually have some idea what they are getting into. With doctors at a conference, it takes just a little longer for them to let their guard down. Improv is an art form and a way to create, it’s a great equalizer and I’ve noticed an evolution in myself as it has changed how I interact. ”

Veronica Samet, a PGY-4 resident from Emory University, Atlanta, added: “In psychiatry, we are taught to leave space in the room for the other person. You get used to compressing yourself into something neutral and it’s hard not to bring that state home. This experience was revitalizing!”

I was delighted to find a friend when I walked into the morning symposium and by the time I left, I felt like I’d made a roomful of friends. We’d played games and I was completely consumed by the tasks at hand. We talked about how each game made us feel, and in some ways this was not all that far off from work as a psychiatrist – the humor and fun were on the surface, but ... or rather, “ ... yes, and” the stories that went along with what we did made for a moment of connection in a whole new way.

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice in Baltimore.

SAN FRANCISCO – A number of years ago, Anne Hanson, Steve Daviss, and I worked together on a psychiatry podcast called “My Three Shrinks.” In the course of making the podcast, Dr. Daviss suggested the three of us should take an improv class together – he felt it would help us blend together better as we interacted to create these dialogues.

We met on Sunday afternoons around one of our dining room tables, often with chili and beer, sometimes with guest psychiatrists, and over the course of a few years, we produced 70 episodes. But we never did take that improv class together.

Steve conveyed that in improv, it’s bad to say, “No, but ...” and instead, one should say, “Yes, and ...” to build upon a theme while working in concert with others. With this limited background, I decided that at this year’s American Psychiatric Association meeting in San Francisco I would report on a session called “You Are Human: Addressing Burnout Through Improv,” organized by Tristan Gorrindo, MD, the director of education and deputy medical director for the APA, and Ashley Whitehurst, a program manager in continuing medical education and faculty at the Second City Training Center, a Chicago-based comedy institution. The session was held on Tuesday morning and was attended by psychiatrists of all training levels. Name badges revealed that attendees were from across the United States and from Canada, Mexico, and one psychiatrist from South Africa.

Before I write about the session on using improv to address physician burnout, I’d like to back up a day, as this was not the first session I found at APA where people were acting out! On Monday, I had gone to a workshop called “Inside OCD: I Am Not My Illness.” I went with the hope of learning something about obsessive-compulsive disorder that I could use to help my patients who suffer from this disorder, with no intention of writing about the session. I was running quite late and chose the session based solely on the title. I stumbled into a rather unusual venue: Patients with OCD were putting on a performance where they discussed how it was to live with the symptoms of this disabling illness, stretched into a humorous storytelling adventure.

The performance group, a joint venture of the Center for Arts in Medicine at the University of Florida in partnership with University of Florida Center for OCD, Anxiety, & Related Disorders consisted of patients who came together in a 10-week course with an acting coach, a resident psychiatrist who participated with the group, and the oversight of their attending psychiatrist, Carol Mathews, MD, to create this collaborative and moving theatrical performance. The group performed, then talked about how this endeavor had helped them to share their stories, to grow in their self-acceptance and self-confidence, and to enjoy a sense of community, and escape from shame and loneliness.

On Monday, I went from the OCD theater to a session called “Unscripting: Using Improvisational Theatre to Move Beyond Personal Limitations.” This workshop was led by Jeffrey Katzman, MD, a psychiatrist who practices in Albuquerque, N.M., and coauthor of “Life Unscripted: Using Improv Principles to Get Unstuck, Boost Confidence, and Transform Your Life.” Dr. Katzman referenced how improv requires the participants to collaborate and respond to one another in ways that are not unlike what occurs in psychotherapy.

“It’s about two people listening to each other, reacting to each other, and ultimately regulating one another.”

A second speaker, Peter Felsman, PhD, LMSW, presented his doctoral dissertation work looking at how improv classes might impact teens with anxiety disorders.

It was at this session that I had my first experiences actually doing some improv exercises. “Improv involves increasing your uncertainty tolerance,” Dr. Katzman noted. “The available scripts are much broader than what you are used to, and they increase the sense of autonomy.” Participants were challenged to work at mirroring the actions of a partner, of switching who was leading in these exercises, and of telling stories where we built upon what the last person gave to the tale by adding unpredictable paths of plot development.

The Tuesday morning session was longer; it lasted from 8 a.m. to 11 a.m. I arrived early, and the first name tag I saw was that of Steven Reidbord, MD, a psychiatrist in San Francisco whom I had never met, but with whom I had interacted many times over the years as we both have had psychiatry blogs. I was delighted as I started the session. Dr. Gorrindo started the symposium by defining physician burnout and discussing how our current system fuels burnout. He discussed his own interest in improv and its use to foster more creative, flexible, and collaborative responses.

Ashley Whitehurst then led the participants in a series of exercises. We walked around the room taking unscripted turns yelling out “I am a star” while the rest of the participants clustered around to frame each individual star! We took partners and discussed a toy each of us had longed for and never gotten in childhood, then created a fictional toy as conglomerate of those toys never received. This light exercise included conversations about the sadness of the toys longed for and the disappointments we’d suffered. One psychiatrist felt gratitude: She had received most of the toys she’d wanted. There were others who’d wanted a real pony or a real typewriter, only to be gifted with disappointing plastic versions. One gentleman longed for a sibling who had died before he had even been born; there were no toys for this space.

Our circle conversations moved into tales we created by interrupting one another with our associations about what we loved and hated; there was the annoyance of having sand in your underwear and superheros who deliver ice cream. We all talked about what it involved to let go of our own agendas and fold into what was going on in the moment, to sway with a plot that changed as soon as it was formed, to function with rules so different from what we were used to. Participants talked about feeling vulnerable, open, playful, and connected. We discussed how improv might be useful in teaching trainees.

“This was interesting and different,” said Sergio Lobato, MD, a psychiatrist from Tijuana, Mexico, who retired after more than 30 years of working in a government hospital. “I saw 20 to 30 patients a day, and there was some burnout. I’m here at the meeting and trying to learn things to help my daughter, who is in her third year of psychiatry training.”

Ms. Whitehurst, our improv instructor, has done many of these workshops with people of all ages and with other groups of physicians. “When people sign up for improv classes, they usually have some idea what they are getting into. With doctors at a conference, it takes just a little longer for them to let their guard down. Improv is an art form and a way to create, it’s a great equalizer and I’ve noticed an evolution in myself as it has changed how I interact. ”

Veronica Samet, a PGY-4 resident from Emory University, Atlanta, added: “In psychiatry, we are taught to leave space in the room for the other person. You get used to compressing yourself into something neutral and it’s hard not to bring that state home. This experience was revitalizing!”

I was delighted to find a friend when I walked into the morning symposium and by the time I left, I felt like I’d made a roomful of friends. We’d played games and I was completely consumed by the tasks at hand. We talked about how each game made us feel, and in some ways this was not all that far off from work as a psychiatrist – the humor and fun were on the surface, but ... or rather, “ ... yes, and” the stories that went along with what we did made for a moment of connection in a whole new way.

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice in Baltimore.

Editor’s note: This is the second in a series of articles by Dr. Miller about challenges in outpatient psychiatry.

Mr. A lived a life that seemed glamorous to me. There were lunches with professional athletes, swank social events, and designer everything from clothes to cars. It was a world that I was not familiar with, and while I knew my patient worried about money, it seemed he had it. When he started therapy with me, Mr. A came to every session with a check. At some point, I realized that I had missed a switch in his mood. Despite his therapeutic level of lithium, Mr. A had become manic, and the expression of this mania took the form of even more spending. What started as an exciting lifestyle suddenly became tens of thousands of dollars of debt. I felt guilty that I initially did not see this as pathology, and as a young psychiatrist, I sought consultation with an older and wiser mentor.

After discussing the case, the consulting psychiatrist said to me, “Make sure you get paid; these cases are difficult.” In fact, in the midst of the chaos, Mr. A had stopped bringing a check to the sessions. I sent monthly statements, and they went unpaid. He didn’t have the money for his living expenses and I let this go on without addressing it for much too long. Soon, Mr. A’s debt to me was just one more stress in his life and while I knew I would not pursue reimbursement through legal channels, I did encourage him to find a psychiatrist who was in his insurance network, something he did not want to do. I was too embarrassed to tell the consulting psychiatrist that Mr. A had already accrued well over a thousand dollars in unpaid professional fees. In my mind, I was offering pro bono care because the patient’s financial circumstances had changed, and because I felt guilty that I had not recognized this as mania sooner.

In a 2011 Shrink Rap blog post, Jesse Hellman, MD, a psychiatrist in private practice in Towson, Md., wrote about the meaning of payment in psychotherapy:

“Money is something loaded with meaning to most people. What does it mean that the patient forgets to pay? Does it mean ‘if you really cared about me you would not charge me’? Is it a reflection of anger for something that occurred in the last session? Is it a displacement of feelings from something else (‘my boss didn’t give me the raise I expected’)? Is it completely inadvertent (Freud famously said ‘Sometimes a cigar is only a cigar’)?”

There are so many possibilities, and the psychodynamic therapist wants to understand them. How the patient relates to the therapist is some part of how he relates to others. The patient hopefully starts to watch his own actions and attitudes and also tries to understand them. A nonjudgmental stance helps the patient do this.

The therapist himself needs to be comfortable dealing with the subject of money. Sometimes beginning physicians fluctuate between feeling they are too inexperienced to be paid and feeling that they deserve anything they ask. We physicians might even (unfortunately) take on the attitudes of the insurance companies themselves (“Identification with the Aggressor”).

The blog post was flooded with comments –120 in total, and more comments than any other single Shrink Rap post received for the blog’s 12-year run.

Steven Reidbord, MD, is a psychiatrist in private practice in San Francisco and also a blogger. Dr. Reidbord conversed with me through email about patients who don’t pay.

“In years past, I’ve had a few patients who met with me a few times, always ‘forgetting’ their payment and offering it ‘next time,’ until after three or four sessions, I refused to see them. I always wondered what such patients were thinking, as obviously this arrangement wouldn’t last long. Did they tell themselves they’d pay me at some point, in effect fooling themselves? Was it conscious theft of my services? A couple years ago, I started accepting charge cards, and perhaps as a result, this hasn’t happened. While it’s always useful to consider individual dynamics in explaining such behavior, it’s also important to consider normative psychology: Make it easier to pay, and more people will.”

While payment for out-of-network services is often clear cut – the patients pay and then requests reimbursement from their insurer – the logistics often are confusing for the patient. He or she may believe that she has excellent coverage, only to learn that the out-of-network deductible is very high, or that reimbursement is based on “usual and customary fees” that are much lower than his psychiatrist’s fees. Sometimes people take on the cost of psychiatric care and discover that it costs more than they assumed, or they have a change in their financial circumstances, as my patient did. Sometimes a parent is paying for treatment and decides he can no longer afford it.

“When someone’s financial circumstances change, they often let me know by proposing we meet less often, for example, every other week,” Dr. Reidbord wrote. “I ask to hear more and often offer to adjust my fee to allow weekly meetings to continue.”

Not all patients pay for psychiatric services, and that may make the discussion even harder. When psychiatrists participate with insurance, the patients are responsible for paying only their deductible and then a copay. The patients may unexpectedly be billed for the entire fee if their insurance terminates, or if it does not pay for a submitted claim. And patients who carry public insurance may be seen at sites where there is no out-of-pocket cost to the patient; salaried clinicians often never know if the insurance has paid. In both of these settings, finances are usually discussed with administrative personnel and not with clinical staff.

Anthony Massey, MD, is founder of Maryland’s Gladstone Psychiatry and Wellness. The group is a multidisciplinary organization, and the clinicians participate with employer-based commercial health insurances. The group accepts payment directly from the insurer, and the patient is responsible for payment of the deductible and a copay.

“We try to understand what someone owes before the first appointment. We do an eligibility check online, and we ask for payment at the time of the appointment,” Massey explained. “Sometimes the insurance changes and we don’t know, or sometimes a patient comes to the appointment without the copay. We try to work with people, but if someone builds up a balance over $500, we tell them they can’t be seen here until it’s paid down. We’ll give patients a 30-day prescription and the names of other psychiatrists who accept insurance, but we don’t keep seeing people who don’t pay for their treatment.”

In all medical settings, unpaid bills present a problem, and while most psychiatrists have a method to deal with these issues, there is no perfect answer for every doctor in every situation. There is this tension between wanting to be kind and understanding of the hardships that people have whether those hardships result from life circumstances or from their own choices and behaviors, and of our own need to make the living we feel we deserve and to pay our own bills.

“The only advice I’d give other psychiatrists is to catch it early,” Reidbord said. “Have a policy that feels fair – payment before each session, payment just after each session, payment soon after receiving a monthly itemized statement, whatever seems right to you – and stick with it. If a patient doesn’t pay according to your clearly stated policy, explore it right away. Remember that pragmatic issues like poor budgeting or unexpected expenses are just as likely as intrapsychic conflict and ‘acting out.’ Both should be considered.”

I wish I could say that in the decades since I treated Mr. A that no patients have ever failed to pay their professional fees and that I have perfectly mastered my own issues with money as it pertains to professional fees. While the vast majority of patients do pay, there are still occasional circumstances in which someone’s financial circumstances change, or very rarely where someone ends his treatment without paying for the last few sessions.
 

Dr. Miller is the coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016) and has a private practice in Baltimore. Patient details were altered to preserve confidentiality.

Editor’s note: This is the second in a series of articles by Dr. Miller about challenges in outpatient psychiatry.

Mr. A lived a life that seemed glamorous to me. There were lunches with professional athletes, swank social events, and designer everything from clothes to cars. It was a world that I was not familiar with, and while I knew my patient worried about money, it seemed he had it. When he started therapy with me, Mr. A came to every session with a check. At some point, I realized that I had missed a switch in his mood. Despite his therapeutic level of lithium, Mr. A had become manic, and the expression of this mania took the form of even more spending. What started as an exciting lifestyle suddenly became tens of thousands of dollars of debt. I felt guilty that I initially did not see this as pathology, and as a young psychiatrist, I sought consultation with an older and wiser mentor.

After discussing the case, the consulting psychiatrist said to me, “Make sure you get paid; these cases are difficult.” In fact, in the midst of the chaos, Mr. A had stopped bringing a check to the sessions. I sent monthly statements, and they went unpaid. He didn’t have the money for his living expenses and I let this go on without addressing it for much too long. Soon, Mr. A’s debt to me was just one more stress in his life and while I knew I would not pursue reimbursement through legal channels, I did encourage him to find a psychiatrist who was in his insurance network, something he did not want to do. I was too embarrassed to tell the consulting psychiatrist that Mr. A had already accrued well over a thousand dollars in unpaid professional fees. In my mind, I was offering pro bono care because the patient’s financial circumstances had changed, and because I felt guilty that I had not recognized this as mania sooner.

In a 2011 Shrink Rap blog post, Jesse Hellman, MD, a psychiatrist in private practice in Towson, Md., wrote about the meaning of payment in psychotherapy:

“Money is something loaded with meaning to most people. What does it mean that the patient forgets to pay? Does it mean ‘if you really cared about me you would not charge me’? Is it a reflection of anger for something that occurred in the last session? Is it a displacement of feelings from something else (‘my boss didn’t give me the raise I expected’)? Is it completely inadvertent (Freud famously said ‘Sometimes a cigar is only a cigar’)?”

There are so many possibilities, and the psychodynamic therapist wants to understand them. How the patient relates to the therapist is some part of how he relates to others. The patient hopefully starts to watch his own actions and attitudes and also tries to understand them. A nonjudgmental stance helps the patient do this.

The therapist himself needs to be comfortable dealing with the subject of money. Sometimes beginning physicians fluctuate between feeling they are too inexperienced to be paid and feeling that they deserve anything they ask. We physicians might even (unfortunately) take on the attitudes of the insurance companies themselves (“Identification with the Aggressor”).

The blog post was flooded with comments –120 in total, and more comments than any other single Shrink Rap post received for the blog’s 12-year run.

Steven Reidbord, MD, is a psychiatrist in private practice in San Francisco and also a blogger. Dr. Reidbord conversed with me through email about patients who don’t pay.

“In years past, I’ve had a few patients who met with me a few times, always ‘forgetting’ their payment and offering it ‘next time,’ until after three or four sessions, I refused to see them. I always wondered what such patients were thinking, as obviously this arrangement wouldn’t last long. Did they tell themselves they’d pay me at some point, in effect fooling themselves? Was it conscious theft of my services? A couple years ago, I started accepting charge cards, and perhaps as a result, this hasn’t happened. While it’s always useful to consider individual dynamics in explaining such behavior, it’s also important to consider normative psychology: Make it easier to pay, and more people will.”

While payment for out-of-network services is often clear cut – the patients pay and then requests reimbursement from their insurer – the logistics often are confusing for the patient. He or she may believe that she has excellent coverage, only to learn that the out-of-network deductible is very high, or that reimbursement is based on “usual and customary fees” that are much lower than his psychiatrist’s fees. Sometimes people take on the cost of psychiatric care and discover that it costs more than they assumed, or they have a change in their financial circumstances, as my patient did. Sometimes a parent is paying for treatment and decides he can no longer afford it.

“When someone’s financial circumstances change, they often let me know by proposing we meet less often, for example, every other week,” Dr. Reidbord wrote. “I ask to hear more and often offer to adjust my fee to allow weekly meetings to continue.”

Not all patients pay for psychiatric services, and that may make the discussion even harder. When psychiatrists participate with insurance, the patients are responsible for paying only their deductible and then a copay. The patients may unexpectedly be billed for the entire fee if their insurance terminates, or if it does not pay for a submitted claim. And patients who carry public insurance may be seen at sites where there is no out-of-pocket cost to the patient; salaried clinicians often never know if the insurance has paid. In both of these settings, finances are usually discussed with administrative personnel and not with clinical staff.

Anthony Massey, MD, is founder of Maryland’s Gladstone Psychiatry and Wellness. The group is a multidisciplinary organization, and the clinicians participate with employer-based commercial health insurances. The group accepts payment directly from the insurer, and the patient is responsible for payment of the deductible and a copay.

“We try to understand what someone owes before the first appointment. We do an eligibility check online, and we ask for payment at the time of the appointment,” Massey explained. “Sometimes the insurance changes and we don’t know, or sometimes a patient comes to the appointment without the copay. We try to work with people, but if someone builds up a balance over $500, we tell them they can’t be seen here until it’s paid down. We’ll give patients a 30-day prescription and the names of other psychiatrists who accept insurance, but we don’t keep seeing people who don’t pay for their treatment.”

In all medical settings, unpaid bills present a problem, and while most psychiatrists have a method to deal with these issues, there is no perfect answer for every doctor in every situation. There is this tension between wanting to be kind and understanding of the hardships that people have whether those hardships result from life circumstances or from their own choices and behaviors, and of our own need to make the living we feel we deserve and to pay our own bills.

“The only advice I’d give other psychiatrists is to catch it early,” Reidbord said. “Have a policy that feels fair – payment before each session, payment just after each session, payment soon after receiving a monthly itemized statement, whatever seems right to you – and stick with it. If a patient doesn’t pay according to your clearly stated policy, explore it right away. Remember that pragmatic issues like poor budgeting or unexpected expenses are just as likely as intrapsychic conflict and ‘acting out.’ Both should be considered.”

I wish I could say that in the decades since I treated Mr. A that no patients have ever failed to pay their professional fees and that I have perfectly mastered my own issues with money as it pertains to professional fees. While the vast majority of patients do pay, there are still occasional circumstances in which someone’s financial circumstances change, or very rarely where someone ends his treatment without paying for the last few sessions.
 

Dr. Miller is the coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016) and has a private practice in Baltimore. Patient details were altered to preserve confidentiality.

Editor’s note: This is the second in a series of articles by Dr. Miller about challenges in outpatient psychiatry.

Mr. A lived a life that seemed glamorous to me. There were lunches with professional athletes, swank social events, and designer everything from clothes to cars. It was a world that I was not familiar with, and while I knew my patient worried about money, it seemed he had it. When he started therapy with me, Mr. A came to every session with a check. At some point, I realized that I had missed a switch in his mood. Despite his therapeutic level of lithium, Mr. A had become manic, and the expression of this mania took the form of even more spending. What started as an exciting lifestyle suddenly became tens of thousands of dollars of debt. I felt guilty that I initially did not see this as pathology, and as a young psychiatrist, I sought consultation with an older and wiser mentor.

After discussing the case, the consulting psychiatrist said to me, “Make sure you get paid; these cases are difficult.” In fact, in the midst of the chaos, Mr. A had stopped bringing a check to the sessions. I sent monthly statements, and they went unpaid. He didn’t have the money for his living expenses and I let this go on without addressing it for much too long. Soon, Mr. A’s debt to me was just one more stress in his life and while I knew I would not pursue reimbursement through legal channels, I did encourage him to find a psychiatrist who was in his insurance network, something he did not want to do. I was too embarrassed to tell the consulting psychiatrist that Mr. A had already accrued well over a thousand dollars in unpaid professional fees. In my mind, I was offering pro bono care because the patient’s financial circumstances had changed, and because I felt guilty that I had not recognized this as mania sooner.

In a 2011 Shrink Rap blog post, Jesse Hellman, MD, a psychiatrist in private practice in Towson, Md., wrote about the meaning of payment in psychotherapy:

“Money is something loaded with meaning to most people. What does it mean that the patient forgets to pay? Does it mean ‘if you really cared about me you would not charge me’? Is it a reflection of anger for something that occurred in the last session? Is it a displacement of feelings from something else (‘my boss didn’t give me the raise I expected’)? Is it completely inadvertent (Freud famously said ‘Sometimes a cigar is only a cigar’)?”

There are so many possibilities, and the psychodynamic therapist wants to understand them. How the patient relates to the therapist is some part of how he relates to others. The patient hopefully starts to watch his own actions and attitudes and also tries to understand them. A nonjudgmental stance helps the patient do this.

The therapist himself needs to be comfortable dealing with the subject of money. Sometimes beginning physicians fluctuate between feeling they are too inexperienced to be paid and feeling that they deserve anything they ask. We physicians might even (unfortunately) take on the attitudes of the insurance companies themselves (“Identification with the Aggressor”).

The blog post was flooded with comments –120 in total, and more comments than any other single Shrink Rap post received for the blog’s 12-year run.

Steven Reidbord, MD, is a psychiatrist in private practice in San Francisco and also a blogger. Dr. Reidbord conversed with me through email about patients who don’t pay.

“In years past, I’ve had a few patients who met with me a few times, always ‘forgetting’ their payment and offering it ‘next time,’ until after three or four sessions, I refused to see them. I always wondered what such patients were thinking, as obviously this arrangement wouldn’t last long. Did they tell themselves they’d pay me at some point, in effect fooling themselves? Was it conscious theft of my services? A couple years ago, I started accepting charge cards, and perhaps as a result, this hasn’t happened. While it’s always useful to consider individual dynamics in explaining such behavior, it’s also important to consider normative psychology: Make it easier to pay, and more people will.”

While payment for out-of-network services is often clear cut – the patients pay and then requests reimbursement from their insurer – the logistics often are confusing for the patient. He or she may believe that she has excellent coverage, only to learn that the out-of-network deductible is very high, or that reimbursement is based on “usual and customary fees” that are much lower than his psychiatrist’s fees. Sometimes people take on the cost of psychiatric care and discover that it costs more than they assumed, or they have a change in their financial circumstances, as my patient did. Sometimes a parent is paying for treatment and decides he can no longer afford it.

“When someone’s financial circumstances change, they often let me know by proposing we meet less often, for example, every other week,” Dr. Reidbord wrote. “I ask to hear more and often offer to adjust my fee to allow weekly meetings to continue.”

Not all patients pay for psychiatric services, and that may make the discussion even harder. When psychiatrists participate with insurance, the patients are responsible for paying only their deductible and then a copay. The patients may unexpectedly be billed for the entire fee if their insurance terminates, or if it does not pay for a submitted claim. And patients who carry public insurance may be seen at sites where there is no out-of-pocket cost to the patient; salaried clinicians often never know if the insurance has paid. In both of these settings, finances are usually discussed with administrative personnel and not with clinical staff.

Anthony Massey, MD, is founder of Maryland’s Gladstone Psychiatry and Wellness. The group is a multidisciplinary organization, and the clinicians participate with employer-based commercial health insurances. The group accepts payment directly from the insurer, and the patient is responsible for payment of the deductible and a copay.

“We try to understand what someone owes before the first appointment. We do an eligibility check online, and we ask for payment at the time of the appointment,” Massey explained. “Sometimes the insurance changes and we don’t know, or sometimes a patient comes to the appointment without the copay. We try to work with people, but if someone builds up a balance over $500, we tell them they can’t be seen here until it’s paid down. We’ll give patients a 30-day prescription and the names of other psychiatrists who accept insurance, but we don’t keep seeing people who don’t pay for their treatment.”

In all medical settings, unpaid bills present a problem, and while most psychiatrists have a method to deal with these issues, there is no perfect answer for every doctor in every situation. There is this tension between wanting to be kind and understanding of the hardships that people have whether those hardships result from life circumstances or from their own choices and behaviors, and of our own need to make the living we feel we deserve and to pay our own bills.

“The only advice I’d give other psychiatrists is to catch it early,” Reidbord said. “Have a policy that feels fair – payment before each session, payment just after each session, payment soon after receiving a monthly itemized statement, whatever seems right to you – and stick with it. If a patient doesn’t pay according to your clearly stated policy, explore it right away. Remember that pragmatic issues like poor budgeting or unexpected expenses are just as likely as intrapsychic conflict and ‘acting out.’ Both should be considered.”

I wish I could say that in the decades since I treated Mr. A that no patients have ever failed to pay their professional fees and that I have perfectly mastered my own issues with money as it pertains to professional fees. While the vast majority of patients do pay, there are still occasional circumstances in which someone’s financial circumstances change, or very rarely where someone ends his treatment without paying for the last few sessions.
 

Dr. Miller is the coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016) and has a private practice in Baltimore. Patient details were altered to preserve confidentiality.

Editor’s Note: This is the first in a series of articles by Dr. Miller about challenges in outpatient psychiatry.

“I don’t understand why it’s so hard for me to get up and get started in the mornings,” my patient said. She was on the verge of losing her job for repeatedly being late to work.

“I really believe you’d have an easier time if you didn’t drink every night then start your mornings with that wake-up shot of gin,” I replied.

“Here we go again,” she said, exasperated with me.

It was a conversation that has been going on for years (literally) and with which we have both been quite frustrated. My patient wants to get better, she asks for my help, and then she refuses any solutions I might suggest.

Patients with addictions have their own challenges; this patient does not want to stop drinking and all my efforts to suggest that alcohol is part of the problem simply don’t matter. When it became clear that it was not simply a matter of her willingness to believe that alcohol was a problem, I made stronger suggestions. She should try a 12-step program, and when that recommendation was scorned, I insisted she go to an outpatient intensive program and pressed the name and phone number into her palm. There have been prescriptions for oral naltrexone, which initially was helpful until the patient stopped taking it, and an offer for a topiramate trial. At the suggestion of a colleague, I even offered to go with her to an intake for substance use treatment. None of my efforts, however, change the fact that this patient does not want these interventions, and our treatment plans don’t seem to converge.

Patients with addictions are often complex, and the forces in play are more than simply the agreement that a problem exists and a desire to stop. Patients who want – yet don’t want – help come in many varieties. We’ve all sat with patients who refuse to take the medications we prescribe or who come back appointment after appointment still never having turned on the lightbox we convinced them to purchase. There are patients who are miserably troubled by being overweight but are not open to changing their diet, exercising, joining a weight-loss group, taking medications, or having bariatric surgery. There are patients who insist they can’t stop smoking but won’t give any of the available treatments a try. There are those we badger to get the lab work that make it safe for them to continue on the medications we prescribe. There are moments when we may wonder what more we have to offer patients who either can’t or won’t follow our suggestions, what may have once been considered “doctor’s orders.”

These are the patients we’ve referred to as “noncompliant.” It’s a term that recently has been questioned, and one that implies a willful refusal to abide by a physician’s decision. Often, it’s worth exploring what holds them back from following our directions. The term noncompliance implies that the person is a bad patient and it does not leave room for the idea that the patient may not agree with the diagnosis or treatment plan or is unwilling to accept the cost or risk of the prescribed solution. Sometimes, understanding what leads a patient to resist can be helpful; unwarranted fears can be addressed and logistical barriers may be overcome.

In some cases, these patient encounters may leave us feeling helpless and worried. In the worst of these cases, where a patient’s refusal to follow through with treatment suggestions may leave them vulnerable to very bad outcomes, I personally have had times when I’ve felt like I’m standing by helplessly watching as a Mack truck speeds into a brick wall.

“In my experience noncompliance is almost always a sign of deeper resistance or ambivalence that needs to be explored,” notes Neha Jain, MD, a geriatric psychiatrist at the University of Connecticut, Farmington.

Dr. Jain communicated with me about patients who don’t want to take the medications she recommends. “A typical scenario is when a patient comes to see me, but says that either they don’t believe in medications or are extraordinarily sensitive to them. I almost always offer medication as a choice and am quick to offer not taking medication as an option for those who are safe. If they refuse, I’ll review their goals and talk about why they came to see me, a primarily prescribing psychiatrist. This often leads to a deeper discussion of why they are resistant to meds, ranging from the stigma of ‘taking a crazy pill’ to what taking a medication means for their ego. For these patients I might offer a few ‘consulting’ sessions, which are really therapy sessions. Often they either become receptive to taking medicines, or they may continue with therapy alone, either with me or with someone else.”

Peter D. Kramer, MD, a psychiatrist in Providence, R.I., and author of “Ordinarily Well: The Case for Antidepressants,” says that the issues are even more complex when patients hide that they have not complied with the psychiatrist’s recommendations. “It seems to me that noncompliance that remains secret, not discussed with the therapist and then discovered incidentally or belatedly, presents an occasion to consider the success of the therapeutic alliance – in older terms, to think more about the transference.”

Dr. Kramer notes that, as our approach to psychotherapy has changed, the psychiatrist’s response to such behavior has also changed. “The prevailing focus on cognitive therapies assumes that when patients realize that a belief or behavior is illogical, they will correct it. When psychotherapy was more analytic, it focused on the reasons patients engaged in irrational and self-destructive acts repeatedly – and patients’ failure to self-correct didn’t frustrate the therapist so much. Instead you thought, ‘If education worked, I’d be out of a job.’ We deal with failures to trust. We deal with what philosophers call weakness of will. While I can’t say that I am never frustrated or surprised, I do see working with these problems as the reason I am there.”

Sometimes we learn that the patient who dismisses our suggestions has already tried the remedies we are suggesting and is just as frustrated as we are. We may be left with the unfortunate situation that nothing we do seems to foster meaningful change for the patient. In these instances it may be helpful to clarify the goals of treatment and inquire whether he feels he is making progress. We may consider trying other forms of treatment, consultation with another clinician, or more intensive therapy if the patient will agree. Other times, we may be left to rethink our treatment, consider the ways in which the patient does find the treatment helpful, and empathize with our patient’s distress while continuing to gently suggest that there might be options available whenever they feel ready.

So my patient did lose her job. She found another position with more flexible hours and, despite her heavy drinking, her life has gone mostly well. She comes to see me only rarely because the medication I prescribe helps stabilize her mood, but she stopped scheduling her regular psychotherapy sessions. Still, while she manages her life around her drinking, I worry about the toll it is taking, as there has been ample evidence that her body cannot sustain this for much longer. From what I can tell, the fact that I remain available is helpful to both the patient and her family but yes, it’s a little like standing by helplessly and watching a Mack truck race toward a brick wall.

Dr. Miller is the coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016) and has a private practice in Baltimore. Patient details were altered to preserve confidentiality.

Editor’s Note: This is the first in a series of articles by Dr. Miller about challenges in outpatient psychiatry.

“I don’t understand why it’s so hard for me to get up and get started in the mornings,” my patient said. She was on the verge of losing her job for repeatedly being late to work.

“I really believe you’d have an easier time if you didn’t drink every night then start your mornings with that wake-up shot of gin,” I replied.

“Here we go again,” she said, exasperated with me.

It was a conversation that has been going on for years (literally) and with which we have both been quite frustrated. My patient wants to get better, she asks for my help, and then she refuses any solutions I might suggest.

Patients with addictions have their own challenges; this patient does not want to stop drinking and all my efforts to suggest that alcohol is part of the problem simply don’t matter. When it became clear that it was not simply a matter of her willingness to believe that alcohol was a problem, I made stronger suggestions. She should try a 12-step program, and when that recommendation was scorned, I insisted she go to an outpatient intensive program and pressed the name and phone number into her palm. There have been prescriptions for oral naltrexone, which initially was helpful until the patient stopped taking it, and an offer for a topiramate trial. At the suggestion of a colleague, I even offered to go with her to an intake for substance use treatment. None of my efforts, however, change the fact that this patient does not want these interventions, and our treatment plans don’t seem to converge.

Patients with addictions are often complex, and the forces in play are more than simply the agreement that a problem exists and a desire to stop. Patients who want – yet don’t want – help come in many varieties. We’ve all sat with patients who refuse to take the medications we prescribe or who come back appointment after appointment still never having turned on the lightbox we convinced them to purchase. There are patients who are miserably troubled by being overweight but are not open to changing their diet, exercising, joining a weight-loss group, taking medications, or having bariatric surgery. There are patients who insist they can’t stop smoking but won’t give any of the available treatments a try. There are those we badger to get the lab work that make it safe for them to continue on the medications we prescribe. There are moments when we may wonder what more we have to offer patients who either can’t or won’t follow our suggestions, what may have once been considered “doctor’s orders.”

These are the patients we’ve referred to as “noncompliant.” It’s a term that recently has been questioned, and one that implies a willful refusal to abide by a physician’s decision. Often, it’s worth exploring what holds them back from following our directions. The term noncompliance implies that the person is a bad patient and it does not leave room for the idea that the patient may not agree with the diagnosis or treatment plan or is unwilling to accept the cost or risk of the prescribed solution. Sometimes, understanding what leads a patient to resist can be helpful; unwarranted fears can be addressed and logistical barriers may be overcome.

In some cases, these patient encounters may leave us feeling helpless and worried. In the worst of these cases, where a patient’s refusal to follow through with treatment suggestions may leave them vulnerable to very bad outcomes, I personally have had times when I’ve felt like I’m standing by helplessly watching as a Mack truck speeds into a brick wall.

“In my experience noncompliance is almost always a sign of deeper resistance or ambivalence that needs to be explored,” notes Neha Jain, MD, a geriatric psychiatrist at the University of Connecticut, Farmington.

Dr. Jain communicated with me about patients who don’t want to take the medications she recommends. “A typical scenario is when a patient comes to see me, but says that either they don’t believe in medications or are extraordinarily sensitive to them. I almost always offer medication as a choice and am quick to offer not taking medication as an option for those who are safe. If they refuse, I’ll review their goals and talk about why they came to see me, a primarily prescribing psychiatrist. This often leads to a deeper discussion of why they are resistant to meds, ranging from the stigma of ‘taking a crazy pill’ to what taking a medication means for their ego. For these patients I might offer a few ‘consulting’ sessions, which are really therapy sessions. Often they either become receptive to taking medicines, or they may continue with therapy alone, either with me or with someone else.”

Peter D. Kramer, MD, a psychiatrist in Providence, R.I., and author of “Ordinarily Well: The Case for Antidepressants,” says that the issues are even more complex when patients hide that they have not complied with the psychiatrist’s recommendations. “It seems to me that noncompliance that remains secret, not discussed with the therapist and then discovered incidentally or belatedly, presents an occasion to consider the success of the therapeutic alliance – in older terms, to think more about the transference.”

Dr. Kramer notes that, as our approach to psychotherapy has changed, the psychiatrist’s response to such behavior has also changed. “The prevailing focus on cognitive therapies assumes that when patients realize that a belief or behavior is illogical, they will correct it. When psychotherapy was more analytic, it focused on the reasons patients engaged in irrational and self-destructive acts repeatedly – and patients’ failure to self-correct didn’t frustrate the therapist so much. Instead you thought, ‘If education worked, I’d be out of a job.’ We deal with failures to trust. We deal with what philosophers call weakness of will. While I can’t say that I am never frustrated or surprised, I do see working with these problems as the reason I am there.”

Sometimes we learn that the patient who dismisses our suggestions has already tried the remedies we are suggesting and is just as frustrated as we are. We may be left with the unfortunate situation that nothing we do seems to foster meaningful change for the patient. In these instances it may be helpful to clarify the goals of treatment and inquire whether he feels he is making progress. We may consider trying other forms of treatment, consultation with another clinician, or more intensive therapy if the patient will agree. Other times, we may be left to rethink our treatment, consider the ways in which the patient does find the treatment helpful, and empathize with our patient’s distress while continuing to gently suggest that there might be options available whenever they feel ready.

So my patient did lose her job. She found another position with more flexible hours and, despite her heavy drinking, her life has gone mostly well. She comes to see me only rarely because the medication I prescribe helps stabilize her mood, but she stopped scheduling her regular psychotherapy sessions. Still, while she manages her life around her drinking, I worry about the toll it is taking, as there has been ample evidence that her body cannot sustain this for much longer. From what I can tell, the fact that I remain available is helpful to both the patient and her family but yes, it’s a little like standing by helplessly and watching a Mack truck race toward a brick wall.

Dr. Miller is the coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016) and has a private practice in Baltimore. Patient details were altered to preserve confidentiality.

Editor’s Note: This is the first in a series of articles by Dr. Miller about challenges in outpatient psychiatry.

“I don’t understand why it’s so hard for me to get up and get started in the mornings,” my patient said. She was on the verge of losing her job for repeatedly being late to work.

“I really believe you’d have an easier time if you didn’t drink every night then start your mornings with that wake-up shot of gin,” I replied.

“Here we go again,” she said, exasperated with me.

It was a conversation that has been going on for years (literally) and with which we have both been quite frustrated. My patient wants to get better, she asks for my help, and then she refuses any solutions I might suggest.

Patients with addictions have their own challenges; this patient does not want to stop drinking and all my efforts to suggest that alcohol is part of the problem simply don’t matter. When it became clear that it was not simply a matter of her willingness to believe that alcohol was a problem, I made stronger suggestions. She should try a 12-step program, and when that recommendation was scorned, I insisted she go to an outpatient intensive program and pressed the name and phone number into her palm. There have been prescriptions for oral naltrexone, which initially was helpful until the patient stopped taking it, and an offer for a topiramate trial. At the suggestion of a colleague, I even offered to go with her to an intake for substance use treatment. None of my efforts, however, change the fact that this patient does not want these interventions, and our treatment plans don’t seem to converge.

Patients with addictions are often complex, and the forces in play are more than simply the agreement that a problem exists and a desire to stop. Patients who want – yet don’t want – help come in many varieties. We’ve all sat with patients who refuse to take the medications we prescribe or who come back appointment after appointment still never having turned on the lightbox we convinced them to purchase. There are patients who are miserably troubled by being overweight but are not open to changing their diet, exercising, joining a weight-loss group, taking medications, or having bariatric surgery. There are patients who insist they can’t stop smoking but won’t give any of the available treatments a try. There are those we badger to get the lab work that make it safe for them to continue on the medications we prescribe. There are moments when we may wonder what more we have to offer patients who either can’t or won’t follow our suggestions, what may have once been considered “doctor’s orders.”

These are the patients we’ve referred to as “noncompliant.” It’s a term that recently has been questioned, and one that implies a willful refusal to abide by a physician’s decision. Often, it’s worth exploring what holds them back from following our directions. The term noncompliance implies that the person is a bad patient and it does not leave room for the idea that the patient may not agree with the diagnosis or treatment plan or is unwilling to accept the cost or risk of the prescribed solution. Sometimes, understanding what leads a patient to resist can be helpful; unwarranted fears can be addressed and logistical barriers may be overcome.

In some cases, these patient encounters may leave us feeling helpless and worried. In the worst of these cases, where a patient’s refusal to follow through with treatment suggestions may leave them vulnerable to very bad outcomes, I personally have had times when I’ve felt like I’m standing by helplessly watching as a Mack truck speeds into a brick wall.

“In my experience noncompliance is almost always a sign of deeper resistance or ambivalence that needs to be explored,” notes Neha Jain, MD, a geriatric psychiatrist at the University of Connecticut, Farmington.

Dr. Jain communicated with me about patients who don’t want to take the medications she recommends. “A typical scenario is when a patient comes to see me, but says that either they don’t believe in medications or are extraordinarily sensitive to them. I almost always offer medication as a choice and am quick to offer not taking medication as an option for those who are safe. If they refuse, I’ll review their goals and talk about why they came to see me, a primarily prescribing psychiatrist. This often leads to a deeper discussion of why they are resistant to meds, ranging from the stigma of ‘taking a crazy pill’ to what taking a medication means for their ego. For these patients I might offer a few ‘consulting’ sessions, which are really therapy sessions. Often they either become receptive to taking medicines, or they may continue with therapy alone, either with me or with someone else.”

Peter D. Kramer, MD, a psychiatrist in Providence, R.I., and author of “Ordinarily Well: The Case for Antidepressants,” says that the issues are even more complex when patients hide that they have not complied with the psychiatrist’s recommendations. “It seems to me that noncompliance that remains secret, not discussed with the therapist and then discovered incidentally or belatedly, presents an occasion to consider the success of the therapeutic alliance – in older terms, to think more about the transference.”

Dr. Kramer notes that, as our approach to psychotherapy has changed, the psychiatrist’s response to such behavior has also changed. “The prevailing focus on cognitive therapies assumes that when patients realize that a belief or behavior is illogical, they will correct it. When psychotherapy was more analytic, it focused on the reasons patients engaged in irrational and self-destructive acts repeatedly – and patients’ failure to self-correct didn’t frustrate the therapist so much. Instead you thought, ‘If education worked, I’d be out of a job.’ We deal with failures to trust. We deal with what philosophers call weakness of will. While I can’t say that I am never frustrated or surprised, I do see working with these problems as the reason I am there.”

Sometimes we learn that the patient who dismisses our suggestions has already tried the remedies we are suggesting and is just as frustrated as we are. We may be left with the unfortunate situation that nothing we do seems to foster meaningful change for the patient. In these instances it may be helpful to clarify the goals of treatment and inquire whether he feels he is making progress. We may consider trying other forms of treatment, consultation with another clinician, or more intensive therapy if the patient will agree. Other times, we may be left to rethink our treatment, consider the ways in which the patient does find the treatment helpful, and empathize with our patient’s distress while continuing to gently suggest that there might be options available whenever they feel ready.

So my patient did lose her job. She found another position with more flexible hours and, despite her heavy drinking, her life has gone mostly well. She comes to see me only rarely because the medication I prescribe helps stabilize her mood, but she stopped scheduling her regular psychotherapy sessions. Still, while she manages her life around her drinking, I worry about the toll it is taking, as there has been ample evidence that her body cannot sustain this for much longer. From what I can tell, the fact that I remain available is helpful to both the patient and her family but yes, it’s a little like standing by helplessly and watching a Mack truck race toward a brick wall.

Dr. Miller is the coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016) and has a private practice in Baltimore. Patient details were altered to preserve confidentiality.

You may have noticed that one of topics I like to write about in this column is the assault on the practice of medicine: the obligations that steal our time from patients without either the value or outcomes our patients see. It is these extraneous demands on our time and on our psyches that dehumanize medical practice as experienced by our patients and contribute to physician burnout. High on my list is the requirement for prior authorization for medications.

In 2015, I wrote a column, “Prior Authorization for Medications: Who oversees placement of the hoops?” The article followed my unsuccessful 6-week-long endeavor to get modafinil authorized for a patient. My efforts included interactions with the insurance company’s chief medical officer, the insurance commissioners in three states, my U.S. senator, and finally, the American Psychiatric Association’s attorney, Colleen Coyle, who has been working on this issue along with the American Medical Association and other medical specialty organizations for years now. The irony of the article is that, after it came out, a reader informed me that modafinil could be obtained from Costco for $34 for 30 pills, while every pharmacy I had checked was selling the generic medication for nearly $1,000 for the same number of pills!

One might make the case that prior authorization saves money by rationing the most expensive medications. And I might counter that physicians should be willing to try less expensive medications first – if we only knew the price of the medications we are prescribing. There is, however, no clear logic to the tremendous variability in price across pharmacies, which can amount to hundreds of dollars a month in the cost to an uninsured patient, and none of which reflects what might be a negotiated cost for those using health insurance. The newest medications are expensive from any retailer, but when it comes to older generics, it’s a crapshoot.

Years have passed since my prior authorization fiasco. Today, I keep a GoodRx app on my phone and often reference it when prescribing medications that might be expensive at one pharmacy but not at another. The app tells me that I can now buy 30 pills of the modafinil for $40.34 at grocery store pharmacy that is 2.7 miles from my office or for $305.50 at Walgreens, 3.6 miles away. A quick call to Costco shows that the price there has gone up to $40.89. For the prescriptions that I have written since that article, I have told patients that their insurance providers may not authorize the medication and if that is the case, they should price shop, as I don’t have the tenacity to go through the prior authorization process I endured in 2015.

So what progress has the APA made over the past 4 years? I wrote back to the APA’s attorney, Ms. Coyle, to ask for an update. Ms. Coyle was kind enough to respond in some detail. It was heartening to hear that in many states, my own state of Maryland included, prior authorization is no longer allowed for medications used to treat opiate addictions, and there is one less obstacle to obtaining care for a growing number of patients during our overdose epidemic.

Other news, however, is not all good. Medicare plans to increase the use of prior authorization.

Ms. Coyle provided data that confirmed what most physicians suspected. “The AMA did a survey¹ and found 92% of physicians report that ‘prior authorizations programs have a negative impact on patient clinical outcomes.’ The AMA study revealed that ‘every week a medical practice completes an average of 29.1 prior authorization requirements per physician, which takes an average of 14.6 hours to process – the equivalent of nearly two business days.’ ”

She recounted the efforts the APA has made on behalf of psychiatrists. “We are working with the AMA and other physician groups to address the issue and recommended [Health and Human Services] address the burden of prior authorization as part of its Patients over Paperwork Initiative.² Through our website and the helpline, we collected stories from our members about the burden it causes and the negative impact it has on patient care. We’ve shared the stories with the American Medical Association to use in joint advocacy efforts with the administration and private insurers.”

Finally, the APA has written a letter to the Centers for Medicare & Medicaid Services in opposition to a proposal for increased utilization review of Medicare Part D protected classes medications, which include antipsychotics and antidepressants. “We strongly oppose the proposal,” Ms. Coyle noted, “and asked our district branches to also submit letters in opposition.”

What can individual psychiatrists do to advocate? I noted that many of my efforts were futile. My U.S. senator responded with a letter that said my problem was not in his domain.

“As for the best way to approach the issue in the state, we recommend working with the state medical society to push for legislation. The AMA has draft legislation that may be used. It would also be helpful to collect the stories from the members about their challenges with prior authorization and impact on patient care/outcomes to share with state legislatures. It may also be beneficial to share these concerns with the state insurance commissioner and Department of Health and Human Services,” Ms. Coyle wrote. She noted it would be helpful for members to work directly with the district branches of the APA.

I am still left with some sense of futility. In 2014, Danielle Ofri, MD, PhD, a physician and writer, wrote an op-ed³ for the New York Times, “Adventures in ‘Prior Authorization,’ ” where she detailed the egregious practice. In the past 5 years, not much has changed, and insurers have not taken to the idea that preserving physician time for clinical care and face-to-face interactions with patients is the priority that we all might like it to be.

Dr. Miller is the coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice in Baltimore.

References

1. AMA Prior Authorization Physician Survey, 2017.

2. CMS Patients Over Paperwork Initiative, CMS.gov.

3. New York Times, Aug. 3, 2014.

You may have noticed that one of topics I like to write about in this column is the assault on the practice of medicine: the obligations that steal our time from patients without either the value or outcomes our patients see. It is these extraneous demands on our time and on our psyches that dehumanize medical practice as experienced by our patients and contribute to physician burnout. High on my list is the requirement for prior authorization for medications.

In 2015, I wrote a column, “Prior Authorization for Medications: Who oversees placement of the hoops?” The article followed my unsuccessful 6-week-long endeavor to get modafinil authorized for a patient. My efforts included interactions with the insurance company’s chief medical officer, the insurance commissioners in three states, my U.S. senator, and finally, the American Psychiatric Association’s attorney, Colleen Coyle, who has been working on this issue along with the American Medical Association and other medical specialty organizations for years now. The irony of the article is that, after it came out, a reader informed me that modafinil could be obtained from Costco for $34 for 30 pills, while every pharmacy I had checked was selling the generic medication for nearly $1,000 for the same number of pills!

One might make the case that prior authorization saves money by rationing the most expensive medications. And I might counter that physicians should be willing to try less expensive medications first – if we only knew the price of the medications we are prescribing. There is, however, no clear logic to the tremendous variability in price across pharmacies, which can amount to hundreds of dollars a month in the cost to an uninsured patient, and none of which reflects what might be a negotiated cost for those using health insurance. The newest medications are expensive from any retailer, but when it comes to older generics, it’s a crapshoot.

Years have passed since my prior authorization fiasco. Today, I keep a GoodRx app on my phone and often reference it when prescribing medications that might be expensive at one pharmacy but not at another. The app tells me that I can now buy 30 pills of the modafinil for $40.34 at grocery store pharmacy that is 2.7 miles from my office or for $305.50 at Walgreens, 3.6 miles away. A quick call to Costco shows that the price there has gone up to $40.89. For the prescriptions that I have written since that article, I have told patients that their insurance providers may not authorize the medication and if that is the case, they should price shop, as I don’t have the tenacity to go through the prior authorization process I endured in 2015.

So what progress has the APA made over the past 4 years? I wrote back to the APA’s attorney, Ms. Coyle, to ask for an update. Ms. Coyle was kind enough to respond in some detail. It was heartening to hear that in many states, my own state of Maryland included, prior authorization is no longer allowed for medications used to treat opiate addictions, and there is one less obstacle to obtaining care for a growing number of patients during our overdose epidemic.

Other news, however, is not all good. Medicare plans to increase the use of prior authorization.

Ms. Coyle provided data that confirmed what most physicians suspected. “The AMA did a survey¹ and found 92% of physicians report that ‘prior authorizations programs have a negative impact on patient clinical outcomes.’ The AMA study revealed that ‘every week a medical practice completes an average of 29.1 prior authorization requirements per physician, which takes an average of 14.6 hours to process – the equivalent of nearly two business days.’ ”

She recounted the efforts the APA has made on behalf of psychiatrists. “We are working with the AMA and other physician groups to address the issue and recommended [Health and Human Services] address the burden of prior authorization as part of its Patients over Paperwork Initiative.² Through our website and the helpline, we collected stories from our members about the burden it causes and the negative impact it has on patient care. We’ve shared the stories with the American Medical Association to use in joint advocacy efforts with the administration and private insurers.”

Finally, the APA has written a letter to the Centers for Medicare & Medicaid Services in opposition to a proposal for increased utilization review of Medicare Part D protected classes medications, which include antipsychotics and antidepressants. “We strongly oppose the proposal,” Ms. Coyle noted, “and asked our district branches to also submit letters in opposition.”

What can individual psychiatrists do to advocate? I noted that many of my efforts were futile. My U.S. senator responded with a letter that said my problem was not in his domain.

“As for the best way to approach the issue in the state, we recommend working with the state medical society to push for legislation. The AMA has draft legislation that may be used. It would also be helpful to collect the stories from the members about their challenges with prior authorization and impact on patient care/outcomes to share with state legislatures. It may also be beneficial to share these concerns with the state insurance commissioner and Department of Health and Human Services,” Ms. Coyle wrote. She noted it would be helpful for members to work directly with the district branches of the APA.

I am still left with some sense of futility. In 2014, Danielle Ofri, MD, PhD, a physician and writer, wrote an op-ed³ for the New York Times, “Adventures in ‘Prior Authorization,’ ” where she detailed the egregious practice. In the past 5 years, not much has changed, and insurers have not taken to the idea that preserving physician time for clinical care and face-to-face interactions with patients is the priority that we all might like it to be.

Dr. Miller is the coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice in Baltimore.

References

1. AMA Prior Authorization Physician Survey, 2017.

2. CMS Patients Over Paperwork Initiative, CMS.gov.

3. New York Times, Aug. 3, 2014.

You may have noticed that one of topics I like to write about in this column is the assault on the practice of medicine: the obligations that steal our time from patients without either the value or outcomes our patients see. It is these extraneous demands on our time and on our psyches that dehumanize medical practice as experienced by our patients and contribute to physician burnout. High on my list is the requirement for prior authorization for medications.

In 2015, I wrote a column, “Prior Authorization for Medications: Who oversees placement of the hoops?” The article followed my unsuccessful 6-week-long endeavor to get modafinil authorized for a patient. My efforts included interactions with the insurance company’s chief medical officer, the insurance commissioners in three states, my U.S. senator, and finally, the American Psychiatric Association’s attorney, Colleen Coyle, who has been working on this issue along with the American Medical Association and other medical specialty organizations for years now. The irony of the article is that, after it came out, a reader informed me that modafinil could be obtained from Costco for $34 for 30 pills, while every pharmacy I had checked was selling the generic medication for nearly $1,000 for the same number of pills!

One might make the case that prior authorization saves money by rationing the most expensive medications. And I might counter that physicians should be willing to try less expensive medications first – if we only knew the price of the medications we are prescribing. There is, however, no clear logic to the tremendous variability in price across pharmacies, which can amount to hundreds of dollars a month in the cost to an uninsured patient, and none of which reflects what might be a negotiated cost for those using health insurance. The newest medications are expensive from any retailer, but when it comes to older generics, it’s a crapshoot.

Years have passed since my prior authorization fiasco. Today, I keep a GoodRx app on my phone and often reference it when prescribing medications that might be expensive at one pharmacy but not at another. The app tells me that I can now buy 30 pills of the modafinil for $40.34 at grocery store pharmacy that is 2.7 miles from my office or for $305.50 at Walgreens, 3.6 miles away. A quick call to Costco shows that the price there has gone up to $40.89. For the prescriptions that I have written since that article, I have told patients that their insurance providers may not authorize the medication and if that is the case, they should price shop, as I don’t have the tenacity to go through the prior authorization process I endured in 2015.

So what progress has the APA made over the past 4 years? I wrote back to the APA’s attorney, Ms. Coyle, to ask for an update. Ms. Coyle was kind enough to respond in some detail. It was heartening to hear that in many states, my own state of Maryland included, prior authorization is no longer allowed for medications used to treat opiate addictions, and there is one less obstacle to obtaining care for a growing number of patients during our overdose epidemic.

Other news, however, is not all good. Medicare plans to increase the use of prior authorization.

Ms. Coyle provided data that confirmed what most physicians suspected. “The AMA did a survey¹ and found 92% of physicians report that ‘prior authorizations programs have a negative impact on patient clinical outcomes.’ The AMA study revealed that ‘every week a medical practice completes an average of 29.1 prior authorization requirements per physician, which takes an average of 14.6 hours to process – the equivalent of nearly two business days.’ ”

She recounted the efforts the APA has made on behalf of psychiatrists. “We are working with the AMA and other physician groups to address the issue and recommended [Health and Human Services] address the burden of prior authorization as part of its Patients over Paperwork Initiative.² Through our website and the helpline, we collected stories from our members about the burden it causes and the negative impact it has on patient care. We’ve shared the stories with the American Medical Association to use in joint advocacy efforts with the administration and private insurers.”

Finally, the APA has written a letter to the Centers for Medicare & Medicaid Services in opposition to a proposal for increased utilization review of Medicare Part D protected classes medications, which include antipsychotics and antidepressants. “We strongly oppose the proposal,” Ms. Coyle noted, “and asked our district branches to also submit letters in opposition.”

What can individual psychiatrists do to advocate? I noted that many of my efforts were futile. My U.S. senator responded with a letter that said my problem was not in his domain.

“As for the best way to approach the issue in the state, we recommend working with the state medical society to push for legislation. The AMA has draft legislation that may be used. It would also be helpful to collect the stories from the members about their challenges with prior authorization and impact on patient care/outcomes to share with state legislatures. It may also be beneficial to share these concerns with the state insurance commissioner and Department of Health and Human Services,” Ms. Coyle wrote. She noted it would be helpful for members to work directly with the district branches of the APA.

I am still left with some sense of futility. In 2014, Danielle Ofri, MD, PhD, a physician and writer, wrote an op-ed³ for the New York Times, “Adventures in ‘Prior Authorization,’ ” where she detailed the egregious practice. In the past 5 years, not much has changed, and insurers have not taken to the idea that preserving physician time for clinical care and face-to-face interactions with patients is the priority that we all might like it to be.

Dr. Miller is the coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice in Baltimore.

References

1. AMA Prior Authorization Physician Survey, 2017.

2. CMS Patients Over Paperwork Initiative, CMS.gov.

3. New York Times, Aug. 3, 2014.

As a medical student in New York City in the mid-1980s, I did several of my clinical clerkships at Memorial Sloan Kettering Cancer Center. One night during my general surgery rotation, there was a young woman with anal cancer who complained of pain.

wildpixel/Thinkstock

My resident did not want to give her more medication and I asked why. After all, this was a cancer center with progressive ideas about pain management, this patient was suffering, and she was ill enough to be hospitalized.

The resident responded to my inquiry: “She doesn’t have a terminal condition and she has an addictive personality.” It seemed to me a draconian (and perhaps sexist) response in a hospital where patient-controlled analgesia was becoming routine and, as an aspiring psychiatrist, I didn’t quite trust the surgical resident’s evaluation of the patient’s personality or his ability to predict if she might become addicted to opiates.

This encounter happened about 6 years after Jane Porter and Hershel Jink, MD, had published a letter titled, “Addiction Rare in Patients Treated with Narcotics” in the New England Journal of Medicine (1980 Jan 10;302:123) with the following finding: “... of 11,800 patients given narcotic painkillers while in hospital, only four developed an addiction to those drugs.” This fragment of a sentence, published as a one-paragraph letter and not as a full, peer-reviewed study, was in the process of changing how all of American medicine responded to pain.

In his book, “Dreamland: The True Tale of America’s Opiate Epidemic” (Bloomsbury Press, 2015), journalist Sam Quinones was quick to point out that these findings were made at a time when doctors, like my surgical resident, were hesitant to use opiates for fear of addiction. Their use was limited to cancer patients, postoperative patients, and those suffering from an acute injury. This finding that prescribed opiates did not cause addiction was true in these hospitalized patients, at a time when pills were doled out with caution for short-term use, and their use for chronic pain had not yet been tested.

Nearly 40 years later, we know that the answer to that national experiment did not work out so well: A proportion of patients given long-term, sometimes high-dose, opiates for chronic pain do sometimes become addicted. Some chronic pain patients received narcotics at “pill mills,” and some went on to use heroin obtained illegally. Furthermore, the widespread use of these medicines made them more readily available to those looking for something besides pain relief.

I would like to suggest that the opioid epidemic is not solely the fault of the medical community: We had drug addiction long before we had the Porter and Jink paragraph and not all addiction starts with a prescription pad. Still, the lesson for public health is a poignant one: Populations and circumstances matter. Be careful with generalizations.

Still, we see these generalizations all the time. I am sometimes surprised at how many people have “the answer.” Whether it’s more widespread availability of Narcan, medication-assisted treatment (MAT), safe injection sites, 12-step programs, or “Just Say No,” every method has its proponents. I always wonder when I see public health officials propose safe injection sites as something that would surely save thousands of lives, citing data out of cities such as Vancouver, as well as in Europe, and Australia, if results in those places would transfer to my city – Baltimore – where drug addiction, violence, and poverty are rampant. Perhaps they would, and I would love to see Baltimore try anything that might work. But I hope cities that do set up such sites will follow the numbers and halt any program that does not offer robust results.

I wonder, as well, why, with the clear success of MAT strategies in reducing mortality, we don’t experiment with ways of making these methods more accessible. Might Suboxone work if doctors could prescribe it as easily as they can prescribe oxycodone, with no 8-hour course or DEA waiver? Might methadone both work and be more acceptable to patients if given in a way that didn’t require daily travel to a clinic for administration? With such a deadly pervasive epidemic, I wonder also about our focus on treating addiction, when it seems we should have a parallel focus on understanding and addressing the factors that cause addiction. Medical prescribing is but one avenue to addiction, yet we have no understanding as to why some people become addicted when others do not. Shouldn’t we be able to prevent addiction? From Richard Nixon’s “war on drugs” to Donald Trump’s physical border wall, there are many answers, but few solutions.

There are other public health issues that suffer from the same generalizations. In psychiatry, advocacy groups tout involuntary outpatient treatment as a successful way of getting treatment to vulnerable individuals who will not willingly negotiate their own care. While a pilot study at Bellevue showed no benefit to mandated care, a follow-up study showed that mandated treatment was effective at reducing hospital days. While outpatient commitment studies look at rates of hospitalization, incarceration, and quality-of-life measures, mandated treatment is often cited as a means to prevent all forms of violence, including mass shootings, while there is no evidence to support these ideas. Still, 47 states and the District of Columbia now have outpatient commitment laws.

Does involuntary care benefit those with substance use disorders? In Massachusetts, Section 35 allows for civil commitment for drug treatment, and many of the treatment facilities are run by the Department of Corrections. It would be good to know if these measures worked. So far, it looks like opioid deaths in Massachusetts have stabilized, while the overdose death rate continues to rise in other states. Whether this is a result of Section 35 or other measures is unknown.

I’m not against innovation, and desperate situations call for creative responses. We need to be careful that our responses are measured and these experiments are contained while ascertaining what really does work and what does not cause unintended harms. Will a concrete wall stem the flow of illegal heroin? I imagine a new world of drones making drug drops.

Sometimes our innovative best guesses don’t work, and sometimes they do. Despite easy access to antidepressant medications, a national suicide hotline, increased numbers of mental health professionals, and anti-stigma/awareness campaigns, suicide rates continue to rise. Efforts to end smoking, however, have been quite successful, as have measures to get Americans to buckle their seat belts, and these measures have decreased mortality rates. The recommendation for healthy women to take hormone therapy is a good example: It was an innovative recommendation to help cardiac and orthopedic outcomes, yet studies that were run alongside these recommendations were quick to show an unintended increased risk of breast and uterine cancer.

I don’t know what happened to the young woman on my surgical rotation. If the decision were mine, I would have given her more pain medication, even now, but I don’t know if that would have been the right thing to do. Before we embrace any measure as a panacea for any of our many societal woes, it’s important to carefully consider the details of our evidence, and to look carefully at our outcomes in a variety of populations and circumstances.

 

Dr. Miller is the coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice in Baltimore.

As a medical student in New York City in the mid-1980s, I did several of my clinical clerkships at Memorial Sloan Kettering Cancer Center. One night during my general surgery rotation, there was a young woman with anal cancer who complained of pain.

wildpixel/Thinkstock

My resident did not want to give her more medication and I asked why. After all, this was a cancer center with progressive ideas about pain management, this patient was suffering, and she was ill enough to be hospitalized.

The resident responded to my inquiry: “She doesn’t have a terminal condition and she has an addictive personality.” It seemed to me a draconian (and perhaps sexist) response in a hospital where patient-controlled analgesia was becoming routine and, as an aspiring psychiatrist, I didn’t quite trust the surgical resident’s evaluation of the patient’s personality or his ability to predict if she might become addicted to opiates.

This encounter happened about 6 years after Jane Porter and Hershel Jink, MD, had published a letter titled, “Addiction Rare in Patients Treated with Narcotics” in the New England Journal of Medicine (1980 Jan 10;302:123) with the following finding: “... of 11,800 patients given narcotic painkillers while in hospital, only four developed an addiction to those drugs.” This fragment of a sentence, published as a one-paragraph letter and not as a full, peer-reviewed study, was in the process of changing how all of American medicine responded to pain.

In his book, “Dreamland: The True Tale of America’s Opiate Epidemic” (Bloomsbury Press, 2015), journalist Sam Quinones was quick to point out that these findings were made at a time when doctors, like my surgical resident, were hesitant to use opiates for fear of addiction. Their use was limited to cancer patients, postoperative patients, and those suffering from an acute injury. This finding that prescribed opiates did not cause addiction was true in these hospitalized patients, at a time when pills were doled out with caution for short-term use, and their use for chronic pain had not yet been tested.

Nearly 40 years later, we know that the answer to that national experiment did not work out so well: A proportion of patients given long-term, sometimes high-dose, opiates for chronic pain do sometimes become addicted. Some chronic pain patients received narcotics at “pill mills,” and some went on to use heroin obtained illegally. Furthermore, the widespread use of these medicines made them more readily available to those looking for something besides pain relief.

I would like to suggest that the opioid epidemic is not solely the fault of the medical community: We had drug addiction long before we had the Porter and Jink paragraph and not all addiction starts with a prescription pad. Still, the lesson for public health is a poignant one: Populations and circumstances matter. Be careful with generalizations.

Still, we see these generalizations all the time. I am sometimes surprised at how many people have “the answer.” Whether it’s more widespread availability of Narcan, medication-assisted treatment (MAT), safe injection sites, 12-step programs, or “Just Say No,” every method has its proponents. I always wonder when I see public health officials propose safe injection sites as something that would surely save thousands of lives, citing data out of cities such as Vancouver, as well as in Europe, and Australia, if results in those places would transfer to my city – Baltimore – where drug addiction, violence, and poverty are rampant. Perhaps they would, and I would love to see Baltimore try anything that might work. But I hope cities that do set up such sites will follow the numbers and halt any program that does not offer robust results.

I wonder, as well, why, with the clear success of MAT strategies in reducing mortality, we don’t experiment with ways of making these methods more accessible. Might Suboxone work if doctors could prescribe it as easily as they can prescribe oxycodone, with no 8-hour course or DEA waiver? Might methadone both work and be more acceptable to patients if given in a way that didn’t require daily travel to a clinic for administration? With such a deadly pervasive epidemic, I wonder also about our focus on treating addiction, when it seems we should have a parallel focus on understanding and addressing the factors that cause addiction. Medical prescribing is but one avenue to addiction, yet we have no understanding as to why some people become addicted when others do not. Shouldn’t we be able to prevent addiction? From Richard Nixon’s “war on drugs” to Donald Trump’s physical border wall, there are many answers, but few solutions.

There are other public health issues that suffer from the same generalizations. In psychiatry, advocacy groups tout involuntary outpatient treatment as a successful way of getting treatment to vulnerable individuals who will not willingly negotiate their own care. While a pilot study at Bellevue showed no benefit to mandated care, a follow-up study showed that mandated treatment was effective at reducing hospital days. While outpatient commitment studies look at rates of hospitalization, incarceration, and quality-of-life measures, mandated treatment is often cited as a means to prevent all forms of violence, including mass shootings, while there is no evidence to support these ideas. Still, 47 states and the District of Columbia now have outpatient commitment laws.

Does involuntary care benefit those with substance use disorders? In Massachusetts, Section 35 allows for civil commitment for drug treatment, and many of the treatment facilities are run by the Department of Corrections. It would be good to know if these measures worked. So far, it looks like opioid deaths in Massachusetts have stabilized, while the overdose death rate continues to rise in other states. Whether this is a result of Section 35 or other measures is unknown.

I’m not against innovation, and desperate situations call for creative responses. We need to be careful that our responses are measured and these experiments are contained while ascertaining what really does work and what does not cause unintended harms. Will a concrete wall stem the flow of illegal heroin? I imagine a new world of drones making drug drops.

Sometimes our innovative best guesses don’t work, and sometimes they do. Despite easy access to antidepressant medications, a national suicide hotline, increased numbers of mental health professionals, and anti-stigma/awareness campaigns, suicide rates continue to rise. Efforts to end smoking, however, have been quite successful, as have measures to get Americans to buckle their seat belts, and these measures have decreased mortality rates. The recommendation for healthy women to take hormone therapy is a good example: It was an innovative recommendation to help cardiac and orthopedic outcomes, yet studies that were run alongside these recommendations were quick to show an unintended increased risk of breast and uterine cancer.

I don’t know what happened to the young woman on my surgical rotation. If the decision were mine, I would have given her more pain medication, even now, but I don’t know if that would have been the right thing to do. Before we embrace any measure as a panacea for any of our many societal woes, it’s important to carefully consider the details of our evidence, and to look carefully at our outcomes in a variety of populations and circumstances.

 

Dr. Miller is the coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice in Baltimore.

As a medical student in New York City in the mid-1980s, I did several of my clinical clerkships at Memorial Sloan Kettering Cancer Center. One night during my general surgery rotation, there was a young woman with anal cancer who complained of pain.

wildpixel/Thinkstock

My resident did not want to give her more medication and I asked why. After all, this was a cancer center with progressive ideas about pain management, this patient was suffering, and she was ill enough to be hospitalized.

The resident responded to my inquiry: “She doesn’t have a terminal condition and she has an addictive personality.” It seemed to me a draconian (and perhaps sexist) response in a hospital where patient-controlled analgesia was becoming routine and, as an aspiring psychiatrist, I didn’t quite trust the surgical resident’s evaluation of the patient’s personality or his ability to predict if she might become addicted to opiates.

This encounter happened about 6 years after Jane Porter and Hershel Jink, MD, had published a letter titled, “Addiction Rare in Patients Treated with Narcotics” in the New England Journal of Medicine (1980 Jan 10;302:123) with the following finding: “... of 11,800 patients given narcotic painkillers while in hospital, only four developed an addiction to those drugs.” This fragment of a sentence, published as a one-paragraph letter and not as a full, peer-reviewed study, was in the process of changing how all of American medicine responded to pain.

In his book, “Dreamland: The True Tale of America’s Opiate Epidemic” (Bloomsbury Press, 2015), journalist Sam Quinones was quick to point out that these findings were made at a time when doctors, like my surgical resident, were hesitant to use opiates for fear of addiction. Their use was limited to cancer patients, postoperative patients, and those suffering from an acute injury. This finding that prescribed opiates did not cause addiction was true in these hospitalized patients, at a time when pills were doled out with caution for short-term use, and their use for chronic pain had not yet been tested.

Nearly 40 years later, we know that the answer to that national experiment did not work out so well: A proportion of patients given long-term, sometimes high-dose, opiates for chronic pain do sometimes become addicted. Some chronic pain patients received narcotics at “pill mills,” and some went on to use heroin obtained illegally. Furthermore, the widespread use of these medicines made them more readily available to those looking for something besides pain relief.

I would like to suggest that the opioid epidemic is not solely the fault of the medical community: We had drug addiction long before we had the Porter and Jink paragraph and not all addiction starts with a prescription pad. Still, the lesson for public health is a poignant one: Populations and circumstances matter. Be careful with generalizations.

Still, we see these generalizations all the time. I am sometimes surprised at how many people have “the answer.” Whether it’s more widespread availability of Narcan, medication-assisted treatment (MAT), safe injection sites, 12-step programs, or “Just Say No,” every method has its proponents. I always wonder when I see public health officials propose safe injection sites as something that would surely save thousands of lives, citing data out of cities such as Vancouver, as well as in Europe, and Australia, if results in those places would transfer to my city – Baltimore – where drug addiction, violence, and poverty are rampant. Perhaps they would, and I would love to see Baltimore try anything that might work. But I hope cities that do set up such sites will follow the numbers and halt any program that does not offer robust results.

I wonder, as well, why, with the clear success of MAT strategies in reducing mortality, we don’t experiment with ways of making these methods more accessible. Might Suboxone work if doctors could prescribe it as easily as they can prescribe oxycodone, with no 8-hour course or DEA waiver? Might methadone both work and be more acceptable to patients if given in a way that didn’t require daily travel to a clinic for administration? With such a deadly pervasive epidemic, I wonder also about our focus on treating addiction, when it seems we should have a parallel focus on understanding and addressing the factors that cause addiction. Medical prescribing is but one avenue to addiction, yet we have no understanding as to why some people become addicted when others do not. Shouldn’t we be able to prevent addiction? From Richard Nixon’s “war on drugs” to Donald Trump’s physical border wall, there are many answers, but few solutions.

There are other public health issues that suffer from the same generalizations. In psychiatry, advocacy groups tout involuntary outpatient treatment as a successful way of getting treatment to vulnerable individuals who will not willingly negotiate their own care. While a pilot study at Bellevue showed no benefit to mandated care, a follow-up study showed that mandated treatment was effective at reducing hospital days. While outpatient commitment studies look at rates of hospitalization, incarceration, and quality-of-life measures, mandated treatment is often cited as a means to prevent all forms of violence, including mass shootings, while there is no evidence to support these ideas. Still, 47 states and the District of Columbia now have outpatient commitment laws.

Does involuntary care benefit those with substance use disorders? In Massachusetts, Section 35 allows for civil commitment for drug treatment, and many of the treatment facilities are run by the Department of Corrections. It would be good to know if these measures worked. So far, it looks like opioid deaths in Massachusetts have stabilized, while the overdose death rate continues to rise in other states. Whether this is a result of Section 35 or other measures is unknown.

I’m not against innovation, and desperate situations call for creative responses. We need to be careful that our responses are measured and these experiments are contained while ascertaining what really does work and what does not cause unintended harms. Will a concrete wall stem the flow of illegal heroin? I imagine a new world of drones making drug drops.

Sometimes our innovative best guesses don’t work, and sometimes they do. Despite easy access to antidepressant medications, a national suicide hotline, increased numbers of mental health professionals, and anti-stigma/awareness campaigns, suicide rates continue to rise. Efforts to end smoking, however, have been quite successful, as have measures to get Americans to buckle their seat belts, and these measures have decreased mortality rates. The recommendation for healthy women to take hormone therapy is a good example: It was an innovative recommendation to help cardiac and orthopedic outcomes, yet studies that were run alongside these recommendations were quick to show an unintended increased risk of breast and uterine cancer.

I don’t know what happened to the young woman on my surgical rotation. If the decision were mine, I would have given her more pain medication, even now, but I don’t know if that would have been the right thing to do. Before we embrace any measure as a panacea for any of our many societal woes, it’s important to carefully consider the details of our evidence, and to look carefully at our outcomes in a variety of populations and circumstances.

 

Dr. Miller is the coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice in Baltimore.

The timing of the Food and Drug Administration’s Nov. 2 approval of the medication Dsuvia, a sublingual formulation of the synthetic opioid sufentanil, is interesting – to say the least. Dsuvia is a powerful pain medication, said to be 10 times more potent than fentanyl and 1,000 times more potent than morphine. The medication, developed by AcelRx Pharmaceuticals for use in medically supervised settings, has an indication for moderate to severe pain, and is packaged in single-dose applicators.

The chairperson of the FDA’s Anesthetic and Analgesics Drug Product Advisory Committee, Raeford E. Brown Jr., MD, a professor of pediatric anesthesia at the University of Kentucky, Lexington, could not be present Oct. 12 at the committee vote recommending approval. With the consumer advocacy group Public Citizen, Dr. Brown wrote a letter to FDA leaders detailing concerns about the new formulation of sufentanil.

“It is my observation,” Dr. Brown wrote, “that once the FDA approves an opioid compound, there are no safeguards as to the population that will be exposed, the postmarketing analysis of prescribing behavior, or the ongoing analysis of the risks of the drug to the general population relative to its benefit to the public health. Briefly stated, for all of the opioids that have been marketed in the last 10 years, there has not been sufficient demonstration of safety, nor has there been postmarketing assessment of who is taking the drug, how often prescribing is inappropriate, and whether there was ever a reason to risk the health of the general population by having one more opioid on the market.”

Dr. Brown went on to detail his concerns about sufentanil. In the intravenous formulation, the medication has been in use for more than two decades.

“It is so potent that abusers of this intravenous formulation often die when they inject the first dose; I have witnessed this in resuscitating physicians, medical students, technicians, and other health care providers, some successfully, as a part of my duties as a clinician in a major academic medical center. Because it is so potent, the dosing volume, whether in the IV formulation or the sublingual form, can be quite small. It is thus an extremely divertible drug, and I predict that we will encounter diversion, abuse, and death within the early months of its availability on the market.”

The letter finishes by criticizing the fact that the full Drug Safety and Risk Management Advisory Committee was not invited to the Oct. 12 meeting, and finally, about the ease of diversion among health care professionals – and anesthesiologists in particular.

Meanwhile, Scott Gottlieb, MD, commissioner of the FDA, posted a lengthy explanation on the organization’s website on Nov. 2, after the vote. In his statement on the agency’s approval of Dsuvia and the FDA’s future consideration of new opioids, Dr. Gottlieb explains: “To address concerns about the potential risks associated with Dsuvia, this product will have strong limitations on its use. It can’t be dispensed to patients for home use and should not be used for more than 72 hours. And it should only be administered by a health care provider using a single-dose applicator. That means it won’t be available at retail pharmacies for patients to take home. These measures to restrict the use of this product only within a supervised health care setting, and not for home use, are important steps to help prevent misuse and abuse of Dsuvia, as well reduce the potential for diversion. Because of the risks of addiction, abuse, and misuse with opioids, Dsuvia also is to be reserved for use in patients for whom alternative pain treatment options have not been tolerated, or are not expected to be tolerated, where existing treatment options have not provided adequate analgesia, or where these alternatives are not expected to provide adequate analgesia.”

In addition to the statement posted on the FDA’s website, Dr. Gottlieb made the approval of Dsuvia the topic of his weekly #SundayTweetorial on Nov. 4. In this venue, Dr. Gottlieb posts tweets on a single topic. On both Twitter and the FDA website, he noted that a major factor in the approval of Dsuvia was advantages it might convey for pain control to soldiers on the battlefield, where oral medications might take time to work and intravenous access might not be possible.

One tweet read: “Whether there’s a need for another powerful opioid in the throes of a massive crisis of addiction is a critical question. As a public health agency, we have an obligation to address this question for patients with pain, for the addiction crisis, for innovators, for all Americans.”

Another tweet stated, “While Dsuvia brings another highly potent opioid to market it fulfills a limited, unmet medical need in treating our nation’s soldiers on the battlefield. That’s why the Pentagon worked closely with the sponsor on developing Dsuvia. FDA committed to prioritize needs of our troops.”

Given our national overdose crisis, and issues of addiction with our soldiers and veterans, one has to wonder if the improvements afforded in pain control by Dsuvia will be worth the trade-off in possible deaths from misdirected use of a very potent agent. And while the new opioid may have been geared toward unmet military needs, Dsuvia will be available for use in civilian medical facilities as well.

There is some irony to the idea that a pharmaceutical company would continue to develop opioids when there is so much need for nonaddictive agents for pain control and so much pressure on physicians to limit access of opiates to pain patients. We are left to stand by and watch as yet another potent opioid preparation is introduced.
 

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016), and assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore.

The timing of the Food and Drug Administration’s Nov. 2 approval of the medication Dsuvia, a sublingual formulation of the synthetic opioid sufentanil, is interesting – to say the least. Dsuvia is a powerful pain medication, said to be 10 times more potent than fentanyl and 1,000 times more potent than morphine. The medication, developed by AcelRx Pharmaceuticals for use in medically supervised settings, has an indication for moderate to severe pain, and is packaged in single-dose applicators.

The chairperson of the FDA’s Anesthetic and Analgesics Drug Product Advisory Committee, Raeford E. Brown Jr., MD, a professor of pediatric anesthesia at the University of Kentucky, Lexington, could not be present Oct. 12 at the committee vote recommending approval. With the consumer advocacy group Public Citizen, Dr. Brown wrote a letter to FDA leaders detailing concerns about the new formulation of sufentanil.

“It is my observation,” Dr. Brown wrote, “that once the FDA approves an opioid compound, there are no safeguards as to the population that will be exposed, the postmarketing analysis of prescribing behavior, or the ongoing analysis of the risks of the drug to the general population relative to its benefit to the public health. Briefly stated, for all of the opioids that have been marketed in the last 10 years, there has not been sufficient demonstration of safety, nor has there been postmarketing assessment of who is taking the drug, how often prescribing is inappropriate, and whether there was ever a reason to risk the health of the general population by having one more opioid on the market.”

Dr. Brown went on to detail his concerns about sufentanil. In the intravenous formulation, the medication has been in use for more than two decades.

“It is so potent that abusers of this intravenous formulation often die when they inject the first dose; I have witnessed this in resuscitating physicians, medical students, technicians, and other health care providers, some successfully, as a part of my duties as a clinician in a major academic medical center. Because it is so potent, the dosing volume, whether in the IV formulation or the sublingual form, can be quite small. It is thus an extremely divertible drug, and I predict that we will encounter diversion, abuse, and death within the early months of its availability on the market.”

The letter finishes by criticizing the fact that the full Drug Safety and Risk Management Advisory Committee was not invited to the Oct. 12 meeting, and finally, about the ease of diversion among health care professionals – and anesthesiologists in particular.

Meanwhile, Scott Gottlieb, MD, commissioner of the FDA, posted a lengthy explanation on the organization’s website on Nov. 2, after the vote. In his statement on the agency’s approval of Dsuvia and the FDA’s future consideration of new opioids, Dr. Gottlieb explains: “To address concerns about the potential risks associated with Dsuvia, this product will have strong limitations on its use. It can’t be dispensed to patients for home use and should not be used for more than 72 hours. And it should only be administered by a health care provider using a single-dose applicator. That means it won’t be available at retail pharmacies for patients to take home. These measures to restrict the use of this product only within a supervised health care setting, and not for home use, are important steps to help prevent misuse and abuse of Dsuvia, as well reduce the potential for diversion. Because of the risks of addiction, abuse, and misuse with opioids, Dsuvia also is to be reserved for use in patients for whom alternative pain treatment options have not been tolerated, or are not expected to be tolerated, where existing treatment options have not provided adequate analgesia, or where these alternatives are not expected to provide adequate analgesia.”

In addition to the statement posted on the FDA’s website, Dr. Gottlieb made the approval of Dsuvia the topic of his weekly #SundayTweetorial on Nov. 4. In this venue, Dr. Gottlieb posts tweets on a single topic. On both Twitter and the FDA website, he noted that a major factor in the approval of Dsuvia was advantages it might convey for pain control to soldiers on the battlefield, where oral medications might take time to work and intravenous access might not be possible.

One tweet read: “Whether there’s a need for another powerful opioid in the throes of a massive crisis of addiction is a critical question. As a public health agency, we have an obligation to address this question for patients with pain, for the addiction crisis, for innovators, for all Americans.”

Another tweet stated, “While Dsuvia brings another highly potent opioid to market it fulfills a limited, unmet medical need in treating our nation’s soldiers on the battlefield. That’s why the Pentagon worked closely with the sponsor on developing Dsuvia. FDA committed to prioritize needs of our troops.”

Given our national overdose crisis, and issues of addiction with our soldiers and veterans, one has to wonder if the improvements afforded in pain control by Dsuvia will be worth the trade-off in possible deaths from misdirected use of a very potent agent. And while the new opioid may have been geared toward unmet military needs, Dsuvia will be available for use in civilian medical facilities as well.

There is some irony to the idea that a pharmaceutical company would continue to develop opioids when there is so much need for nonaddictive agents for pain control and so much pressure on physicians to limit access of opiates to pain patients. We are left to stand by and watch as yet another potent opioid preparation is introduced.
 

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016), and assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore.

The timing of the Food and Drug Administration’s Nov. 2 approval of the medication Dsuvia, a sublingual formulation of the synthetic opioid sufentanil, is interesting – to say the least. Dsuvia is a powerful pain medication, said to be 10 times more potent than fentanyl and 1,000 times more potent than morphine. The medication, developed by AcelRx Pharmaceuticals for use in medically supervised settings, has an indication for moderate to severe pain, and is packaged in single-dose applicators.

The chairperson of the FDA’s Anesthetic and Analgesics Drug Product Advisory Committee, Raeford E. Brown Jr., MD, a professor of pediatric anesthesia at the University of Kentucky, Lexington, could not be present Oct. 12 at the committee vote recommending approval. With the consumer advocacy group Public Citizen, Dr. Brown wrote a letter to FDA leaders detailing concerns about the new formulation of sufentanil.

“It is my observation,” Dr. Brown wrote, “that once the FDA approves an opioid compound, there are no safeguards as to the population that will be exposed, the postmarketing analysis of prescribing behavior, or the ongoing analysis of the risks of the drug to the general population relative to its benefit to the public health. Briefly stated, for all of the opioids that have been marketed in the last 10 years, there has not been sufficient demonstration of safety, nor has there been postmarketing assessment of who is taking the drug, how often prescribing is inappropriate, and whether there was ever a reason to risk the health of the general population by having one more opioid on the market.”

Dr. Brown went on to detail his concerns about sufentanil. In the intravenous formulation, the medication has been in use for more than two decades.

“It is so potent that abusers of this intravenous formulation often die when they inject the first dose; I have witnessed this in resuscitating physicians, medical students, technicians, and other health care providers, some successfully, as a part of my duties as a clinician in a major academic medical center. Because it is so potent, the dosing volume, whether in the IV formulation or the sublingual form, can be quite small. It is thus an extremely divertible drug, and I predict that we will encounter diversion, abuse, and death within the early months of its availability on the market.”

The letter finishes by criticizing the fact that the full Drug Safety and Risk Management Advisory Committee was not invited to the Oct. 12 meeting, and finally, about the ease of diversion among health care professionals – and anesthesiologists in particular.

Meanwhile, Scott Gottlieb, MD, commissioner of the FDA, posted a lengthy explanation on the organization’s website on Nov. 2, after the vote. In his statement on the agency’s approval of Dsuvia and the FDA’s future consideration of new opioids, Dr. Gottlieb explains: “To address concerns about the potential risks associated with Dsuvia, this product will have strong limitations on its use. It can’t be dispensed to patients for home use and should not be used for more than 72 hours. And it should only be administered by a health care provider using a single-dose applicator. That means it won’t be available at retail pharmacies for patients to take home. These measures to restrict the use of this product only within a supervised health care setting, and not for home use, are important steps to help prevent misuse and abuse of Dsuvia, as well reduce the potential for diversion. Because of the risks of addiction, abuse, and misuse with opioids, Dsuvia also is to be reserved for use in patients for whom alternative pain treatment options have not been tolerated, or are not expected to be tolerated, where existing treatment options have not provided adequate analgesia, or where these alternatives are not expected to provide adequate analgesia.”

In addition to the statement posted on the FDA’s website, Dr. Gottlieb made the approval of Dsuvia the topic of his weekly #SundayTweetorial on Nov. 4. In this venue, Dr. Gottlieb posts tweets on a single topic. On both Twitter and the FDA website, he noted that a major factor in the approval of Dsuvia was advantages it might convey for pain control to soldiers on the battlefield, where oral medications might take time to work and intravenous access might not be possible.

One tweet read: “Whether there’s a need for another powerful opioid in the throes of a massive crisis of addiction is a critical question. As a public health agency, we have an obligation to address this question for patients with pain, for the addiction crisis, for innovators, for all Americans.”

Another tweet stated, “While Dsuvia brings another highly potent opioid to market it fulfills a limited, unmet medical need in treating our nation’s soldiers on the battlefield. That’s why the Pentagon worked closely with the sponsor on developing Dsuvia. FDA committed to prioritize needs of our troops.”

Given our national overdose crisis, and issues of addiction with our soldiers and veterans, one has to wonder if the improvements afforded in pain control by Dsuvia will be worth the trade-off in possible deaths from misdirected use of a very potent agent. And while the new opioid may have been geared toward unmet military needs, Dsuvia will be available for use in civilian medical facilities as well.

There is some irony to the idea that a pharmaceutical company would continue to develop opioids when there is so much need for nonaddictive agents for pain control and so much pressure on physicians to limit access of opiates to pain patients. We are left to stand by and watch as yet another potent opioid preparation is introduced.
 

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016), and assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore.