Wednesday, November 20, 2013

Now It's the Cardiologists' Turn

People like to rag on psychiatry: we've got our own anti-psychiatry movement, and one of the biggest issues for these groups is that "psychiatry" (whoever our singular voice might be) misrepresented itself by saying there are chemical imbalances responsible for mental illness, when no precise imbalance has yet been identified.  We're not like internal medicine and it's sub-specialties where there are numbers and a cut-off for when you have diabetes, and when your cholesterol raises your risk of heart disease.  Those numbers are reportedly precise science, but, actually, those illnesses are defined like psychiatric disorders: by consensus of a bunch of people on a committee. 

These days I follow the cardiology news with interest.  Today is the 6 month anniversary of my brother's death from coronary artery disease.  My brother did not know that his coronary arteries were quietly calcifying and by the cardiology predictors, he had no reason to believe he was at any imminent risk of death.  While he once had an elevated cholesterol level, he did what doctors recommend: he changed his eating habits, increased his exercise, and he died with wonderful numbers.  Never a smoker, the one clue that this might have happened was that our father also died of heart disease he didn't know he had, at a very young age.

For a field where things are supposed to be so much more clear cut than psychiatry, cardiology also has it's camps.  There are those who prescribe statins at a very low threshold, and those who feel they are over-prescribed.  Does this sound familiar?   In yesterday's LA Times, there was an article titled Cardiologists Cast Doubt on New Statin Recommendations, while USAToday's article notes Heart Experts Debate Who Should Take StatinsAnd if you'd like a more medical take on this JAMA has "dueling" viewpoints on whether healthy men should take statins HERE and HERE
I guess JAMA doesn't care about cardiac prevention in healthy women?

In psychiatry, we usually get second chances.  In cardiology the camps are frequently life-or-death and 1/3 of people will die during their first heart attack.  In psychiatry, we're nebulous about prognosis.  In cardiology, there are definitive treatments (such as bypass surgery), though cardiac stents are not free of their own angst these days.   Obviously, I now wish my brother had taken a statin and I wish he'd had a calcium score done so he would have known he needed more aggressive intervention.  With the statin's all-too-well publicized side effects, and his successful efforts to modify "risk," it's easier to look back and say what might have been.

In the meantime, the issue in cardiology is about risk, and they do have non-invasive (albeit expensive) ways of getting definitive answers about who does or does not have coronary artery disease.  I'm left to wonder why more at-risk individuals aren't encouraged to undergo such imaging given that the technology is available.

So let me ask this: if an expensive MRI would give you a definitive answer on whether a patient with a psychiatric disorder would respond to a medication, would you order that test?  Pretend the test costs a great deal of money (let's say $5,000), but the treatment is cheap (let's say $10/month)?  If you're the patient, would you pay for the test, or try the cheap medication first, knowing the medication has some risks?  What if you had no symptoms, but were told that a screening test would enable you to stop the progression of a life-changing illness?  What if there was a cheaper version (say $2000) but that entailed radiation while the more expensive test did not? 


jesse said...

Great points. But expand the question: what should the insurer demand? That the cheap medication be tried first? How do we really assess risk/benefit when the consequences of a bad result can be truly devastating?

One thing we have learned here from many people who have had bad results from forced hospitalization is that once a person has experienced a bad outcome the generalization is thrown out the window.

HIGurl said...

Great post to reflect on. Jesse makes a good point with insurance companies. Obviously, they'd probably like to go the cheaper route. You'd think they'd bypass the what-if and pay the money to get an accurate diagnosis. It may actually save them some money down the road, provided these tests aren't over abused.

If I knew an expensive test would give a definitive answer, I would order that test. However, it would ultimately be up to the patient to follow-through, which would be dependent on each individual (e.g., financial situation, pros vs cons).

That said, if I was the patient I think I would pay for the test. Though I've never taken any psychotropic medications, the typical side effects and trial-and-error would prompt me to go the more definitive route. I think I would feel a lot better knowing exactly what medication will work, so that I can feel better (even if I was exposed to radiation). That is, of course, if I recognize any of my symptom(s). For psychiatry, it may be feeling irritable, moody, psychotic, etc. And for cardiology, it may be shortness of breath, chest pain, nausea, etc.

Unless we recognize our symptoms and/or risks (e.g., family history, lifestyle), following up for such tests is like out-of-sight, out-of-mind. I like to call it mental fog. We live in a busy world filled with many different personalities and many different possibilities.

Thanks for a challenging post. I hope all is well...

Anonymous said...

Dinah, on a related note, I asked a psychologist in the comments section of the NY Times article on insomnia and depression if he/she automatically refers people for sleep studies if they have sleeping issues. Folks on this blog may or may not know but I feel I wasted 15 years of my life on psych meds due to undiagnosed apnea and am pretty passionate about this issue.

This person's response was this was done but not always and that he/she felt most people did not have medical sleep disorders which in my opinion is quite debatable. He/she also felt it would be a waste of medical resources if everyone was referred for a sleep study.

Well, to relate it to your points, it may be seem like it is a waste but depending on how many people turn out to have apnea or another sleeping disorder that was masquerading as a psych illness, it actually could be alot cheaper in long run even though it may be more expensive initially.

Also, shouldn't the patient be given that information about the possibility and let him/her make the decision? Why does the psychologist get to decide who to refer, especially when he/she doesn't have a medical background?

Regarding the issue of meds, this isn't about being pro psychiatry vs. anti psychiatry. Really, using that "a" word is really getting old and needs to be put out to pasture.

The issue is about fully informed consent and being honest about what the meds can do and can't do. A British psychiatrist, Johanna Moncrief, who was written a book on the history of antipsychotics said that when the meds first came out, doctors were honest about the drugs suppressing symptoms so that people weren't tormented by voices. Of course, that also had the effect of suppressing higher cognitive functions but at least there was no attempt to hide the fact that drugs did that.

Unfortunately, just like with antidepressants, antipsychotics falsely became a campaign about chemical imbalances which Dr. Moncrief, who is not ant meds, felt was extremely dishonest.

Regarding your brother's tragic death, I agree that he definitely sounded like he needed to be on a statin. But even before this latest controversy, it seemed to me that they were way over prescribed when the evidence didn't support that.

In fact, I knew of stories where it seemed people were getting them thrown at them for as absurd reasons as psych meds have been thrown at people. That is why people get so angry and end up distrusting doctors and the medical profession.

Jesse, great post!


Unknown said...

Thanks for bringing this subject up; great article, as well as comments.

Liz said...

i'm sorry to hear of your brother's death. my brother died suddenly as well, quite a long time ago, and my father died of a heart attack at the age of 47. my experiences with psychiatry and terrible experiences with psychiatric meds have led me to distrust the medical profession in general. i absolutely see what you mean about cardiology being similar in many ways to psychiatry... in addition, it seems that eating well and exercising are extremely important tools to stay healthy heart wise and spirit wise....

Val said...

I could understand going for cheap meds first. However, if treatment is not working then I think it's time to order the MRI. I agree with AA that no one should have to waste 15 years on psych meds that aren't helping.

I remember reading a child pdoc online who was saying that every time he treats a kid, and nothing he tries helps, without fail, there was something else wrong with the kid (allergies, sleep disorder, whatever).

I don't know how many drugs you would have to burn through before anyone would think it would be worth it to run an expensive test, but I do think 15 years is a bit extreme.

As far as a screening test, I think in cases where it is in the person's genetics (family member had the condition) it is worth it. we can't spend our whole lives having tests run. That's no way to live. But a small amount is fine.

And radiation. Oh I dunno. How much? Mammograms and dental xrays already give me enough. Is it just one test that happens once? Probably not that bad.

Unknown said...

As a physician (or an overly-naive pre-med student), I would present the patient with both options. Radiation, on an infrequent basis, will not present a great deal of harm, and though I personally see it as a waste of $5,000, it is ultimately up to them. As the patient, I would go for the cheap drugs. If it doesn't work, oh well. If it does, great. Who cares if the resulting relief is because the drug works really well, or it's a placebo effect? The important thing is that I feel better.

On the second note, it depends on the amount of radiation. I have back problems; if I've had 3 MRI's that year, I might opt toward the lower-radiation test. On the other hand, if the duration of the tests differ, it may not matter. If one takes 15 minutes of higher radiation, and the other 30 minutes of lower radiation, does it matter? It's 6 of one, half a dozen of the other.

Dinah said...

Okay, so in cardiology, there are some non-specific ways to look for coronary artery disease which are not invasive or expensive: the Stress Test -- unless you trip on the treadmill and break something or have a heart attack when the speed goes up (it happens), it's low risk. There are more invasive stress tests, like a thallium stress test, which entails more (I am not up on this). My brother had a negative stress test 10 years ago, pushed to a high level.

The most definitive test is a cardiac catheterization: it's invasive, there are risks, and it's very expensive. But it is definitive. Understandably, it's reserved for those with symptoms.

There is a test called an electron beam CT which yields a calcium score and a look at the heart and arteries. It runs a few hundred dollars, takes a few minutes, is non invasive, and there is a considerable amount of radiation. Last year my brother's doctor suggested this because of family history, and he said he wanted to wait because he felt well. The test shows calcified plaque, not soft placque, so a score of 0 offers some reassurance but it's not perfect, you can still have disease. This test would have identified my brother's problem (he had calcified arteries), but there is no standard that says who you do the test on or at what age and the radiation is considerable.

There is a MRA (a type of MRI) that takes 2 hours, is very expensive, and has no radiation. It's thought to be pretty good for identifying CAD, but experience is more limited.

The last test is an CT-angiogram. There is an IV, contrast, and a large dose of radiation, but it gives excellent images of the coronary arteries along with a calcium score. It costs about $1500 and takes a few minutes.

Needing to know, I debated between the very expensive, but no radiation, 2hour long MRA and a CT-A. I decided on the CT-A because there is more experience with these.

So fiction here: say there was a test that would tell you if a given patient's brain will respond to long-term anti-psychotics? Does a patient take a cheap medicine knowing it might not help, and it might cause weight gain/Diabetes/tardive dyskinesia/fatigue when it might not be necessary? Insurers aren't going to pay to screen everyone.

Je Suis said...

"Insurers aren't going to pay to screen everyone."

True enough, and a statement that sums up a large portion of the problems with health care in this country. The insurer gets to decide what is in your best interest, even when it flies in the face of common sense; because the bottom line, definitive stance when it comes to your healthcare is not 'care' so much as profits - the profits made by the middlemen involved, and demanded by the shareholders of the insurers, hospital corporations, and pharmaceutical companies, to name a few. If it is more profitable to let someone die, these entities are more than willing to do so in the name of profit - and some have, in fact, done so.

Here's a question, then - in a given hypothetical (but often times all too real) situation, Mr. X has lost his job, his insurance, and his unemployment has run out - he's despondent and suicidal, and either threatens or unsuccessfully attempts suicide. He is serious, and therefore is placed in civil commitment against his will. My question is why? Given the parameters above, wherein an insurer can deny definitive treatment options based on costs, why then must an individual, one without the resources to pay the exorbitant price of the unwanted 'care', be forced into that contract? How is this even remotely justifiable? Are we really willing to accept that an insurer is able to deny 'care' based on costs, but that the individual, the one who is directly impacted and who must make these very personal decisions
for himself, cannot? That the individual can be forced to bear the brunt of the onerous costs completely, without the luxury of saying no? Why? Why is it acceptable for the insurer to say no but not the individual?

Dinah said...

Je Suis, the insurer can say no. Or they can say the patient has no mental health benefits. Or that the patient needs to go to another unit. Or that the patient can only be admitted if they sing and dance first, and it must be a specific song and dance. Insurers say No all the time when the patient WANTS to go into the hospital and the doctors agree this is necessary.

When an uninsured patient walks into the emergency room, they know they are incurring a bill.

If they are brought there involuntarily by the police, you've got a good point. I don't have a good answer. But if the uninsured, unemployed, suicidal man ends up involuntarily hospitalized and happens to have a few million in savings, who should pick up the tab?

Je Suis said...

You make my point for me, so thank you. Yes, an insurer can refuse, for all the reasons you mention, or other, even more obfuscate ones - the end result being that, even if you are invested in your health care, and are doing the right things (such as carrying insurance), you might be denied the coverage because, well, who knows? A typo, a clerical error, the procedure, treatment, whatever, is just too expensive, we've changed our coverage and that's no longer an option, the list of reasons is endless. The result is not, however - too frequently, you are not going to get that treatment, or test, or whatever it is you need unless you pay for it first yourself. Maybe you will be reimbursed, maybe not. Health care is a game of Russian roulette, with your financial future in the path of the bullet.

So, yes, when an uninsured patient walks into the emergency room, they know they are incurring a bill, and are therefore responsible. But, many times the insured also incur bills, which they expect their insurance to pay for (after all, that is the point of insurance, to have coverage in case the unexpected occurs), only to discover the payment denied or greatly reduced because someone somewhere decided that it wasn't necessary, or appropriate, or whatever. Health care is a business, insurance is a business, and your care is not the priority. Money is.

Which brings us to our example of a suicidal individual: generally speaking, someone as described (He's serious) will be brought in by the police (or EMT's) against his will. Now, if he does have a few million dollars in savings, then great, although 1) that would be an extremely rare situation, and 2) the point of the example is that he's at the end of his resources, which has led to the suicidal action - but, even then, why should he pay for unwanted intervention? As evinced by fact that one's health care is determined by costs, health care is a business first - why should someone who is not interested in that care be forced into that business transaction in the first place? The simple answer is that there should be no tab if the individual in question does not accept that "care', and if he is indeed forced to accept that 'care', then the entity initiating that force should be the responsible party. Alternately, we should all be able to take out a business license and force people into accepting our product or service - after all, money that is in motion is good for an economy, so there is a certain justification for it in maintaining a healthy economy. I've had a couple business licenses
in my life, and that certainly would have helped to be able to force my services on people who otherwise might not have been interested in what I had to offer.

Dinah said...

Je suis,
You need emergency surgery and the anesthesiologist is not in your network. You were unconscious when the ambulance was called and you never consented to treatment, and certainly not with a physician who would charge you thousands for the procedure.

Many seriously suicidal patients just commit suicide.

Many walk into emergency rooms for help and then are surprised when the doctors want to keep them.

All of those brought into the ER by the police have either done something dangerous (wielded a knife, held up a bottle of pills, uttered a serious threat, posted threats on Facebook), and transmitted to another their intent to harm/injure and put them in an awful situation, because surely the person who calls the police knows the patient is in dire financial straits.

I would not be adverse to the concept of a fun that provided emergency care to those subjected to unwanted psychiatric care, but then might people refuse care just to get it covered.

I totally see your point, I just don't have a great answer. A basic level of National Health Insurance available to everyone perhaps?

Je Suis said...


Your example of the anesthesiologist serves to highlight why healthcare as a business is a bad idea. Let me give you one from my experience: I worked with a woman who developed breast cancer, and underwent treatment for it. During this period, she discovered that the health plan she carried through her provider (a large hospital chain) did not cover the anesthesiologist's charges, despite the fact that the anesthesiologist contracted for, and worked in, the hospital she was an employee of and where she was receiving treatment. This large hospital chain provided no anesthesia coverage for its own employees. Yet, despite the fact that the 'care' providers can refuse to provide, or at least pay for, that care, based on so many different things, the person receiving 'care' cannot refuse? Why? Why is it so one-sided? If you do not want the 'care', you have no say, but if you do, well, you might not get it, or might have to pay for it yourself? And this is a business transaction, it's all about the money at the heart of it, so why must anyone be forced to accept that 'care'?

Despite this, I am ok with providing this 'care' for emergency treatment if the victim is unconscious or otherwise unable to express their wishes. Better to err on the side of caution I suppose. However, once they are capable of making their wishes known, I believe that those wished must be followed, no matter the outcome. This is the natural result of healthcare being a business - an individual should not be forced into any business transaction against their will, ever. If healthcare is a business, then treat it like a business, with people being free to limit or avoid doing business with that entity. Otherwise, we must allow every business to force their goods or services on others. It's really that simple.

The only other answer is to stop treating healthcare as a business, and find a different way to fund it - something other countries have done. But, that has it's own pros and cons. What we have now, however, is some bastardized hybrid
system that always seems to work to the consumer's or patient's disadvantage: pay inflated prices to the insurers (so that they can make a profit), who then limit access to your care (or deny it completely, forcing you to pay again) while also granting you a deductible, so that you have to pay something even if you receive care, and then you get to pay your co-pay or co-insurance (typically 20%) - and this is considered a good healthcare system? it seems more like something Orwell might have written. Yet, it's a business, but one that you can't say no to? What the hell? Whoever designed or allowed this system clearly needs psychiatric 'care' far more than the people who are forced into it.

Je Suis said...

Yes, "many seriously suicidal patients just commit suicide" - but many who try are also unsuccessful, and end up in the ER against their will. Then they have to endure the burdens of 'care' - the financial burdens, the social burdens, the civil burdens, the stigma; all in addition to the problems that brought them to the precipice in the first place. What kind of business is this healthcare
anyway? It seems to make matters worse, at least in this context - so why force it on people?

"Many walk into emergency rooms for help and then are surprised when the doctors want to keep them"
I would venture to guess that they are surprised because, again, it's a business, and what business not only kidnaps their customers and holds them against their will, but also charges them a fee for that kidnapping? Maybe the mob? I don't know of any (including the mob by the way), so I think that surprise is warranted.

"All of those brought into the ER by the police have either done something dangerous" - not entirely true. Sometimes they are brought there based on someone giving false or misleading statements to the police, either intentionally or not. I'm sure you are aware of this. In addition, and I have said this before, sometimes they are held as a matter of petty revenge. I know of one such, wherein a ER patient made the physician mad, and then physician Baker Acted the patient. The social worker questioned this, as the patient did not meet the criteria, and the social services worker was told that that was how the ER doc handled it when someone makes them angry; that it was no big deal, only 3 days and then they would let them go, after all what's 3 days? Understand, I was present for this conversation, so I know it to be true. No harm done, except that a hospital makes most of it's money in the first few days of an admission, and of course it's a business, so there would not be a conflict of interest in holding a patient for a few days against their will when they don't meet the criteria, now would there?

As a matter of interest, I conversed with several of the social workers at this facility, and discovered something interesting: none of them know the
laws concerning the Baker Act. Each one had a different idea as to how it worked, and none were correct. When I pointed this out to one, the answer I got was that the people Baker Acted wouldn't know, either, so it doesn't matter.

So, do you begin to understand the position I am forming my opinions from? There is something inherently wrong in the way the entire process is handled, or mishandled, and the burden is entirely on the patient/victim/consumer, who is at the mercy of an unforgiving and error prone system. One that harms as much as helps.