From the Editor

Unmet needs and hassles of psychiatric practice

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Few things are more aggravating than having to secure preauthorization from an insurance company to hospitalize an acutely ill patient or to prescribe a medication that is not on the insurer’s restrictive formulary.


Recently, my umbrage at these prac­tices soared to a new height when a col­league told me that he had to fight for, and then wait to receive, permission from an insurance employee to increase, by a notch, the maintenance dosage of a long-acting antipsychotic for his patient.

Can anyone justify why an absentee person who has never met the patient should, sight-unseen, second-guess our clinical judgment that a patient’s symptoms are still not well-controlled and require upward adjustment of the dosage? Why are insurance compa­nies allowed to micromanage clinical decision-making? Such outrageous intrusiveness is a signal that insur­ance companies have “jumped the shark” in their effort to push business interests ahead of the needs of their subscribers.

Whose interests are being put first?
I recall instances when I refused to buckle to pressure from a patient’s third-party payer to switch from 1 antidepres­sant to another, a move that would save the insurer money but put my patient at risk of relapse. I informed the insurance company representative that my attor­ney was going to file a lawsuit on behalf of my depressed patient if he were to relapse or attempt suicide because he had been switched from an antidepres­sant that was working to another that might not.

Fighting back paid off: In each case, I was told the payer would “make an exception” for that patient.

Frustrations of this kind have become commonplace in psychiatric practice. They tend to detract from the stimulat­ing and gratifying aspects of the care we provide, and reinforce the perception that insurance companies’ primary goal is to fatten profits, not facilitate patients’ return to health.

Here are other reasons for chronic frustration in psychiatric practice. They reflect serious, unmet needs that we hope will be resolved soon.

Improved diagnostic schema. We need a valid—and more than simply reliable—evidence-based diagnostic system that is rooted in scientifically established pathophysiology. The basic clinical elements of DSM-5 should be gradually amalgamated with rap­idly emerging genetics and biological endophenotypes. The continuum of and boundary between “normal” and “pathologic” human behavior should be further clarified.

Biomarkers. Our field eagerly awaits development of biomarkers (laboratory tests) to bolster psychiatric practice in several ways, including:
• confirming the clinical diagnosis
• identifying biological subtypes
• monitoring response
• guiding selection of drugs
• predicting side effects
• measuring severity of disease.

Elusive parity. We’ve been patient, but we’re tired and angry at empty prom­ises of full parity for psychiatric care. We’ve also had it with the stigmatizing and discriminatory “carve-out” status that allows insurance companies to treat reimbursement for psychiatric services more restrictively than for other medical and surgical specialties. Policy makers must end the egregious discrimination that gives half a loaf to some brain disorders (psychiatric) and a full loaf to other brain disorders (neurologic).

Better medications. We need a stron­ger commitment from the pharma­ceutical industry, on which we rely entirely for development of psycho­active drugs, to wage a relentless war on serious mental illness. The private sector should accelerate translation of groundbreaking neuroscientific dis­coveries—thanks to research funded by the public sector, such as the National Institutes of Health—into innovative new mechanisms of action. Patients who suffer from psychiatric brain disorders for which there are no approved treatments await that com­mitment and bold action.

Collaborative care. Psychiatry needs a more consistent, more produc­tive bidirectional relationship with primary care. A stronger bond will improve the care of patients on both sides and would, I believe, increase the satisfaction of clinical practice for both specialists. Because structure can facilitate function, co-locating provid­ers can help achieve this vision.

Legal entanglement. Psychiatry must be unshackled from an oppres­sive set of laws that tie our hands when we treat patients with brain pathology who are incapable of under­standing their illness and their need to be treated. Those laws were imposed long before scientific advances showed that prolonged and untreated episodes of psychosis, mania, depres­sion, and anxiety are associated with neurotoxic processes (neuroinflam­mation, oxidative and nitrosative stress). Medical urgency and patient protection must trump legalisms, just as unconscious stroke and myocardial infarction patients are treated immedi­ately without filing multiple forms or waiting for a court order.

Another legal beef: We psychiatrists are exasperated with the expand­ing criminalization of our patients— hapless victims of brain diseases that impair their reality testing and behav­ior. Should a person who suffers a first epileptic seizure or a stroke while driv­ing and kills the driver of an oncom­ing car be incarcerated with hardened murderers and rapists and treated for epilepsy in a prison instead of a neu­rology ward? Our patients belong in a secure hospital, a medical asylum, where they are given compassionate medical care, not the degrading treat­ment afforded to a felon.


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