October 1, 2009
Reflections on Psychotherapy
Health care reform highlights more than the changing nature of medicine—it highlights that social change is underpinned by ideologies that vie against each other in a competitive marketplace of ideas and values. I explored that topic in my last blog. In this blog, I reflect on the transformation of psychotherapy in psychiatric practice. I want to begin by acknowledging that sometimes change manifests as a schism between old and new—a sudden break from the past that throws our modes of acting and thinking into disarray. But revolutionary change is extremely rare—there are usually too many stakeholders invested in the existing order of things. The current health care debate is a good example. More often than not, then, change is evolutionary or environmental—we change because we adapt or because the constant drip, drip, drip of external factors wares us into a different form. In the case of gradual transformation it’s only through reflection that we can make sense of the forces acting on us.
From its inception in the late nineteenth century until very recent times, psychotherapy dominated psychiatry. As a therapeutic model it eloquently combines and addresses the biological, psychological, and social dimensions of illness. It powerfully acknowledges the multi-directional nexus between how we think, feel, and act. And yet, psychotherapy has always been somewhat clouded in conjecture. I think that some of that can be attributed to its popularization in the twentieth century which resulted in entertaining, but inaccurate, stereotypes. Say the word “psychotherapy” and many people will envisage the peculiar dynamic of a patient reclining supine as he relates childhood memories to a therapist who sits behind him, out of view, scribbling notes. In a more recent stereotype, the analyst assumes a social accessory role similar to that of the tennis coach, Pilates instructor, or personal trainer. When the psychiatric profession is so often reduced to a caricature, it’s easy to appreciate why the average person could be intimidated by it.
But since the 1990s the fog has thickened around psychotherapy within the psychiatry profession itself. A national survey of outpatient medical practices from 1996 to 2005 revealed that psychotherapy and pharmacotherapy in psychiatry are increasingly split:
The investigators surveyed 14,108 visits to psychiatrists involving a psychiatric diagnosis. The percentage of visits with at least 30 minutes of psychotherapy decreased significantly over 10 years from 44 percent to 29 percent. For patients with private insurance, the decline was significant (from 50 percent to 25 percent), but not for those in publicly funded programs, where the initial percentage was low (Medicare, from 32 percent to 21 percent; Medicaid, from 22 percent to 13 percent). The percentage was highest among self-paying patients and did not change significantly (from 55 percent to 59 percent). In HMOs, the percentage of visits with psychotherapy decreased significantly to a remarkable degree (from 23 percent to 5 percent) (Dubovsky 2008).
In short, psychotherapy is being eroded from psychiatric practice and, upon reflection, there are a number of environmental causes. The most significant factor is an economic one. Psychiatrists who work within managed care programs administered by insurance companies are discouraged from combining psychotherapy with pharmacotherapy. They’re under pressure to see a large number of patients and work within a system that rewards short consultations. The same study revealed that ‘third-party reimbursement to psychiatrists is 41 percent less for one 45-minute psychotherapy session than for three 15-minute "med checks."’ (Dubovsky 2008).
At the same time, there’s been a paradigm shift in psychiatry that focuses on mental illness as a physiological disease—a biological imbalance that can be chemically corrected. As a consequence, there’s stronger emphasis on drugs in psychiatry—a trend which finds favor with pharmaceutical companies, cost-conscious insurers, and patients looking for fast relief. Anti-depressants are now the most commonly prescribed drug in the US. Indeed, psychotropic drugs have revolutionized psychiatry by strengthening the biological component of the biopsychosocial model—but I’ve also seen, over and over, that pharmacotherapy is rarely a complete solution. People are complicated—more complicated than chemistry alone can account for. They ultimately seek to be understood and to understand themselves, not just to be promised that their neurotransmitters will be set right with a pill. It’s the relationship that heals, and the correct formulation of diagnosis and treatment is powerful in, and of, itself.
Think of someone who’s never understood why they think, behave, or feel the way they do, and has suffered greatly most of their life. For example, they may have experienced emotional problems, anxiety, interpersonal difficulties, or failed career aspirations. Now interject another person who’s trained to illuminate reasons—taking into account the biological, social, psychological aspects of their circumstances—in a safe, non-judgmental arena, and at the right point in a patient’s life. The key to improved mental health lies in not only alleviating a patient’s symptoms, but in helping them to understand and address the underlying causes of those symptoms. When a patient improves through insight and understanding, they gain a much better sense of control over their disorder. The result is that they experience a more positive prognosis, which might be more aptly described as a better life.
The pendulum is swinging back as mounting clinical research demonstrates that psychotherapy is more effective than drugs alone in treating many mental disorders. (Refer to the American Psychiatric Foundation for further information about clinical findings). The positive effects of psychotherapy can be measured not only by symptom relief, relapse reduction, and patient wellbeing, but by physiological changes in the brain. They key here is that the growing proof for psychotherapy not only appeals to the medical and scientific community, but that it also piques the interest of penny-wise insurance companies!
Robin Stone, M.D.
Insight Psychiatry
13123 Rosedale Hill Ave.
Huntersville, NC 28078
704-948-3810
References & further reading:
American Psychiatric Foundation 2008 Psychotherapy basics, Mental HealthWorks.
Mojtabai, R & Olfson, M 2008 National trends in psychotherapy by office-based psychiatrists, Archives of General Psychiatry, vol. 65, no. 8.
Dubovsky, S 2008 Psychiatric practice: a march from the brainless to the mindless?, Journal Watch Psychiatry, September 15.
September 6, 2009
When Healers Need Healing
In the last 30 years, ‘burnout’ has turned from a vernacular idiom into a prevalent psychosocial syndrome—one that’s particularly relevant in current times as the economic recession impacts on lifestyles. Surveys reveal that job cuts and the threat of redundancy are affecting work/life balance. Many people are working longer hours and seriously worrying about their job security.
Professional burnout has many characteristics, not least of which include emotional exhaustion, cynicism, and a loss of interest in one’s work or personal life—the feeling of “just going through the motions”. Burnout cuts a broad swathe across professions, but is especially prevalent where occupational stressors—such as heavy workload and constant pressure—are accompanied by other job demands that lead a person to perceive a lack of control in their life.
It’s little surprise, then, that medical professionals are particularly prone to burnout, especially so given the current health crisis. When physicians are surveyed, up to 40 percent of them report feelings of stress and burnout, while a concerning 70 percent report feeling pessimistic about the future of the health care system (Gundersen 2001).
Burnout can be especially dangerous in medicine because it carries potential consequences for patients. Some studies suggest that burned out physicians have more trouble relating to patients, and the quality of the care they provide may suffer—let alone that an increasing number of doctors contemplate early retirement and alternative professions.
Due to fear of recrimination (licensure issues, shame and guilt, and social stigmatization), physicians often avoid or postpone mental health treatment, or attempt to treat themselves secretly. As a case in point, about a third of physicians do not have their own doctor. A concerning pattern occurs where medical professionals often delay seeking help until they hit rock bottom.
The good news is that there’s a growing movement that recognizes the importance of physician health—not only for the benefit of members of the medical profession, but for the wider good of the community. Wellness strategies include methods of recharging one’s physical and mental capacity, emotional self-awareness, connecting with social support systems, and seeking help before stress begins affecting work performance. Research demonstrates greatly reduced burnout rates and improved job satisfaction in physicians who practice these coping strategies (Spickard et al 2002).
As a fellow medical professional, I understand the pressures that make physicians reluctant to seek care, which is why my practice is designed to protect the professional sensitivities of my patients. At my office, for example, there are two separated waiting rooms. Patients enter and exit from different doors, and discrete parking is provided at the rear of the building. Privacy is a very valid concern for medical professionals seeking mental health support, but it should not be an insurmountable obstacle. We must remind ourselves that ‘doing no harm’ begins with our own well-being first.
Robin Stone, M.D.
Insight Psychiatry
13123 Rosedale Hill Ave.
Huntersville, NC 28078
704-948-3810
References & further reading:
Gundersen, L. 2001 ‘Physician burnout’, Annals of Internal Medicine, vol. 135, no.2, pp. 145-148.
Spickard, A., Gabbe S., Christensen, J. 2002 , ‘Mid-career burnout in generalist and specialist physicians’, Journal of the American Medical Association, vol. 288. no. 12.
August 20, 2009
Depression or ‘soft’ bipolar disorder?
Depression is among the top three causes of death and disability in the US (Michaud et al 2006). Consequently, primary care providers spend an increasing amount of time diagnosing and treating mental health disorders. Most patients seeking help for mental health issues will turn to their primary care doctor before approaching a specialist.
A recent study in The Lancet reveals the difficulties primary care doctors encounter in properly diagnosing depression (Kelly 2009). This is not a criticism of primary care providers. Rather, it highlights that mental health disorders can present with many different symptoms and phases.
It is concerning, however, that studies reveal that up to 50 percent of patients diagnosed with recurrent depression have features of mild hypomania, considered the ‘soft’ end of the bipolar spectrum. Clinical research suggests that these patients might be more effectively treated within the framework of bipolar II disorder (Smith 2009).
Hypomania can be difficult to identify because it’s less pronounced than mania. Patients can be unaware of the cycling nature of their mood, and only seek treatment when they’re feeling depressed. As a consequence, patients can be misdiagnosed with depression for years (sometimes decades) before receiving proper diagnosis and treatment. Again, this is not a criticism of primary care providers—bipolar disorder is a complex condition that tests every clinician’s diagnostic acumen and treatment skills. This is especially so for ‘soft’ bipolarity.
What are the consequences of misdiagnosing bipolar II disorder as major depressive disorder? In addition to delayed recovery, the primary concern is that antidepressant medications may carry a risk of worsening some patients’ symptoms. ‘Antidepressant monotherapy for bipolar depression—at least for some patients—can cause more frequent mood episodes, mood destabilization, and possibly an increase in suicidal behaviors’ (Smith 2009).
Patients who are not feeling improvements within a few of weeks of beginning antidepressant therapy should seek specialty care. Diagnosis of bipolar II disorder demands detailed psychiatric assessment. Clinician’s are also encouraged to seek a corroborative history from a close relative of the patient to help identify if hypomania is present. Most bipolar II patients will require a multi-modal therapy approach, including psychotherapy.
I welcome inquiries from mental health professionals and members of the public.
Robin Stone, M.D.
Insight Psychiatry
13123 Rosedale Hill Ave.
Huntersville, NC 28078
704-948-3810
References & further reading:
Smith, DJ 2009 ‘Soft bipolarity: how to recognize and treat bipolar II disorder’, Current Psychiatry, vol. 8, no. 7.
Kelly, J 2009 ‘Depression Often Misdiagnosed in Primary Care’, Medscape.
Michaud, CM et al 2006 ‘The burden of disease and injury in the United States 1996’, Population Health Metrics, vol. 4, no. 11.
Posted by at 9:40 PM | Permalink | Comments (0) | TrackBacks (0)November 30, 2008
Paging Marcus Welby…
If you could get your doctor to change one thing, what would it be? A reasonable question given today’s healthcare environment. Apparently one that sparked quite a few postings in WSJ’s forum section. It appears some physicians feel more satisfied than others. Some see their profession as a privilege and honor…others are frustrated and disempowered by the corporate-driven machine of healthcare. They miss having the time to talk with their patients, and lament about the seven or eight minute visit managed care has allocated for a routine visit, to quote one anonymous reply, “To see twenty-three patients in a day, not spending enough time with any of them--that’s not why I went to medical school.”
The “Physicians’ Foundation” recently launched a press release regarding a physician career satisfaction survey, a poll that has inspired several national papers to comment. Plenty of figures seemed odd: 45% of respondents (which were mostly primary care physicians) stated they would leave medicine entirely if financially able, 60% said they would not recommend medicine as a career to a young person, and 78% believed there is a shortage of primary care docs, the same percentage indicated that medicine was “less rewarding” or “no longer rewarding”. Hmmm, what was the actual number of respondents? Who paid for this study? I for one could not believe my colleagues would have such a disparaging view.
These statistics generalized by the widespread media, (CNN, the Wall Street Journal, Boston Globe and others) look pretty demoralizing on the surface…but, lets look at the study methodology. First, the study was paid for by the Physicians’ Foundation (an organization founded with monies garnered after a class action lawsuit physicians won against third party payors). Second, the survey was performed by Merritt, Hawkins and Associates (a healthcare consulting and physician recruiting firm). Third, and most importantly, the survey was mailed to 320,000 physicians (only 11,950 responded). Now it stands to reason that the people most likely to post on physician discussion boards, or return surveys such as this are dissatisfied e.g.: an impetus for taking time out to respond (If knowledge serves this error is referred to as responder bias—a huge confounder in most survey-based research)
Wouldn’t it be in the interest of Merritt Hawkins to support the notion of a physician shortage? After all, they are in the business of prostituting physicians (oops I mean recruiting) for hospitals and other healthcare entities. Who is the true benefactor here? All of the percentages listed are extrapolated from 12,000 respondents (less than 3.8% of the total number surveyed…and an even smaller percentage of physicians nationwide) How is this representative of what doctors really think about their career decision, or job satisfaction?
To those who would complain about being a physician, get out…your bitching and moaning about the healthcare crisis is not part of the solution. If you don’t like working for the insurance company, or hospital administration, there are plenty of other opportunities to help patients in non-traditional practice models.
If you build it…they will come. www.insight-psychiatry.com
References:
CNN Video - Family doctor shortage
The Physicians' Foundation - Survey
Bostom.com - The crisis of primary care physicians
www.merritthawkins.com
WSJ - Doctors Feel Gloomy, Financially Strapped
Robin Stone, M.D.
Insight Psychiatry
13123 Rosedale Hill Ave.
Huntersville, NC 28078
704-948-3810
January 25, 2008
Sadness is not always “depression”
What is pathology and what is ordinary suffering? In most cases, a few weeks of intense grief following the death of a loved one is ordinary suffering, according to the handbook psychiatrists use to classify mental illness. But the same grief following, say, the loss of a job or the end of a marriage could be classified as depression, a form of mental illness.
A study published March, 2007 in the Archives of General Psychiatry takes issue with that distinction. “Historical precedent, common sense, and research on loss responses all suggest that many types of losses can trigger intense normal sadness,” the authors write, listing a few garden-variety forms of loss: “not only bereavement but also romantic betrayal and rejection, economic misfortune, severe physical illness, loss of cherished possessions, and failure to attain important goals, among others.”
In the study, researchers looked at data from a national mental-health survey and identified respondents who met the standardized criteria for major depressive disorder (which requires multiple symptoms such as gloomy mood, feelings of guilt, and changed eating or sleep patterns), and whose depressive episodes were triggered by bereavement or other specific forms of loss. They found, perhaps not surprisingly, that the bereavement-triggered group was almost identical to the group whose grief was triggered by other forms of loss.
If the Diagnostic and Statistical Manual of Mental Disorders, were to expand the boundaries of ordinary grief to include forms of loss besides bereavement, it could reduce the number of people classified with major depressive disorder by one quarter. A revision which would hopefully cut down on prescriptions for antidepressants that may do more harm than good. (Sorry big pharma) If someone has a normal grief reaction, you wouldn’t give that person an antidepressant, you would favor psychotherapy. If someone has major depression, medication is more likely to have some utility. Does your psychiatrist appreciate the difference between normal sorrow and “depression”? If he or she only wants to talk meds then probably not…
Citations:
Jerome C. Wakefield, PhD; Michael B. First, MD, et al; Extending the Bereavement Exclusion for Major Depression to Other Losses (Evidence From the National Comorbidity Survey) Arch Gen Psychiatry. 2007;64(4):433-440.
Insight Psychiatry
www.insight-psychiatry.com
13123 Rosedale Hill Ave.
Huntersville, NC 28078
704-948-3810
June 19, 2007
Anxiety is as common as depression but receives less attention
Compared with the strong focus on depression, less attention has been paid to anxiety disorders. Using questionnaires and interviews, U.S. researchers found that 188 of 965 consecutive patients at 15 primary care clinics had anxiety disorders, for a prevalence of 20%; 9% had post-traumatic stress disorder, 8% had generalized anxiety disorder, 7% had panic disorder, and 6% had social anxiety disorder. Overall, 41% received no medications, counseling, or psychotherapy.
Anxiety disorders were associated with physical and mental health-related problems and disability. A seven-item screening questionnaire (the Generalized Anxiety Disorder-7 scale) was 77% sensitive and 82% specific for any anxiety disorder. The first two items were less sensitive (65%) but similarly specific (88%). These items asked, "Over the past 2 weeks, how often have you been bothered by the following problems: [1] feeling nervous, anxious or on edge and [2] not being able to stop or control worrying."
This study confirms that in primary care settings, anxiety
disorders are common, are often untreated, and substantially impair health and quality of life.
Citation(s):
Kroenke K et al. Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection. Ann Intern Med 2007 Mar 6; 146:317-25.
Katon W and Roy-Byrne P. Anxiety disorders: Efficient screening is the
first step in improving outcomes. Ann Intern Med 2007 Mar 6; 146:390-2.
Insight Psychiatry
www.insight-psychiatry.com
13123 Rosedale Hill Ave.
Huntersville, NC 28078
704-948-3810
April 10, 2007
Managed care vs. Hippocratic Oath?
Health insurance premiums are rising, reimbursements to physicians are decreasing, and yet insurance companies are thriving. But, that’s business and not the central issue when a patient is not given the respect, and compassion due to anyone who comes before a physician seeking help.
Most state medical boards stress the importance of the patient-physician relationship, some emphasizing that it is “unethical for a physician to allow financial incentives or contractual ties of any kind to adversely affect his or her patient care” (www.ncmedboard.org) This creates an inherent conflict, as most physicians are still playing by the rules set forth by insurance companies. Physicians recognizing the primacy of patient autonomy, and the sacredness of the doctor-patient relationship based on mutual trust, quite frankly, are in a quandary.
Physicians are not taught how to run a business, this is true. But more importantly, most are not willing to buck the system and just say “no” to managed care, or become politically active. They all know that 8 minutes is not enough time for an office visit. It shouldn’t matter whether it takes 12 years to complete medical training, or that professional liability insurance costs are rising.
I would like to see physicians take less time explaining “why”, and instead channel their embitterment in a positive way. For some to be true to their calling, means taking financial risks by opting out of managed care plans or insurance firms that constrain patient care. How can this be wrong when medical boards have clearly stated any delivery of care decision that has been negatively affected by a physician’s contractual ties constitutes unethical behavior?
Insight Psychiatry
www.insight-psychiatry.com
13123 Rosedale Hill Ave.
Huntersville, NC 28078
704-948-3810
April 8, 2007
Depression affects 19 million Americans
Depression does not discriminate. The video titled "The State of Depression in America" features Mike Wallace and gives a fair overview of barriers to treatment, both economic and sociologic. The white paper discusses mental health parity, an informative article for both doctors and patients.
Link to "The State of Depression in America" featuring Mike Wallace.
Insight Psychiatry
13123 Rosedale Hill Ave.
Huntersville, NC 28078
704-948-3810
March 23, 2007
Psychiatry Lake Norman, Huntersville, Cornelius, North Charlotte NC
Posted by at 7:52 PM | Permalink | Comments (0) | TrackBacks (0)March 22, 2007
Robin Stone, M.D. Huntersville NC
Dr. Stone believes that doctors should talk less and listen more; and that humility encourages trust. Through the benefit of experience she has gained an appreciation for the fragility of the human condition, and a deep respect for the resiliency of the human spirit.
Believing that physicians should comfort as well as diagnose, Dr. Stone knows that the healing arts – though guided by science -- also require the human touch. Her philosophy of active listening combined with experience guiding patients toward recovery in many settings helps her achieve exceptional results for those she treats.
About Robin Stone, M.D.
13123 Rosedale Hill Ave.
Huntersville, NC 28078
704-948-3810
Education and Training
Psychiatry Residency, Wake Forest University
Baptist Medical Center, Winston-Salem NC
Medical School, University of Missouri Columbia, MO
Bachelor of Science in Nursing, Rockhurst College
Research Hospital, Kansas City, MO
Bachelor of Science, Psychology, Missouri State University Springfield, MO
Prior Work Experience
· Nurse Manager for 600 bed correctional facility
· Registered Nurse, KC Research Hospital, Pain management unit, oncology, general medical/surgery
· Kansas City Free Health Clinic - HIV drug trial recruiting
· Don Bosco Center - refugee assistance
· Community Living Opportunities -Americans with Disabilities Act awareness presentations, advocacy and job coaching
Professional Society Memberships
· American Medical Association
· North Carolina Medical Society
· American Psychiatric Association
· North Carolina Psychiatric Association
Licensure
· North Carolina Medical License
