“What is Wrong with the Patient?” Part III Treatment Approaches: “What can/should be done for the Patient?”

Overview of Different Treatment Eras The 1 st Biological Psychiatry: 1880s-1920s The Psychoanalytic Hiatus: 1920s-1960s The Rise of the 2 nd Biological Psychiatry: 1950s-1980s The Rise of (Cosmetic) Psychopharmacology: 1990s-present

The 1 st Biological Psychiatry Industrialization and the necessary “medicalization” of mental health and psychiatry in late 1890s and early 1900s major advances in understanding biological origins of many several mental illnesses first occurred in Europe (France, Britain, and especially Germany)... definitely not in America e.g., neurosyphilis and “madness” -end stage of neurosyphilis was treated in public asylums and clinics -“shameful” disease meant most people did not receive treatment for it -evolution of disease took on mental symptoms of increasing severity

The 1 st Biological Psychiatry neurosyphilitic madness No other disease in which primarily middle-aged men (mainly whites) suddenly became demented and then died paralyzed with terminal convulsions. flooded European mental asylums in the 19 th century, along with an extraordinary increase in patients with severe alcoholism and those with schizophrenia

The 1 st Biological Psychiatry Advanced link between neurology and psychiatry found in European mental asylums by clinicians who tracked the progression and resolution of these mental diseases Emil Kraepelin ( ) - kept data cards on each patient - “discovered” schizophrenia and manic-depression worked with Aloys Alzheimer at the Heidelberg Clinic - they began to spot distinct and predictable patterns of disease progression by virtue of both mental and physiological symptoms

The 1 st Biological Psychiatry Kraepelin’s ultimate dichotomy of insanity: (1)those with an affective component (had better prognosis) - mood disorder: depressed, manic, anxious “manic-depressive illness” (2)those without an affective component (had worse prognosis) - psychotic in the absence of an affective component “schizophrenia”

The 1 st Biological Psychiatry Kraepelin’s structure insisted that there were a number of discrete psychiatric illnesses, or diseases, each separate from the next. Depression, schizophrenia, and so forth were different just as mumps and pneumonia were different. “medical model” of mental illness temporarily adopted by America’s “Kraepelin”: Adolph Meyer returned to Worcester State Hospital/Asylum and then moved to Johns Hopkins ( ) Meyer ultimately rejected Kraepelin’s model Psychiatrist Adolf Meyer sailing to Europe.

The Psychoanalytic Hiatus Asylum practice came to be seen as “dead end,” even as the numbers of patients admitted to them continued to increase. American psychiatrists wanted to shift the focus of their work to private practice and attract a middle-class clientele. Freud to the rescue (trained as a neurologist) Freud: repressed childhood sexual memories and fantasies caused neurosis (or psychosis) when reactivated in adult life. Leisurely introspection became the form of treatment.

The Psychoanalytic Hiatus American origins: 1909 visit by Freud to Clark University Key catalyst: “The Arrival of the Europeans” in the 1930s Years of triumph: late 1940s to late 1960s Symptoms were meaningless because disease entities didn’t mean anything when it came to mental illness Practically everyone had some measure of mental maladjustment. Question: What else made psychoanalytic and dynamic psychiatry so popular?

The Psychoanalytic Hiatus deep insulin coma therapy, ECT Metrozol shock therapy, lobotomy

The Rise of the 2 nd Biological Psychiatry Lithium* (not FDA-approved until 1970) Chlorpromazine (Thorazine) Reserpine Meprobamate (Miltown) Haloperidol (Haldol) Imipramine (Tofranil) Iproniazid (MOAI) Librium (Valium) Methylphenidate (Ritalin) Leo Sternbach, inventor of Valium, died on September 28, 2005, aged 97

The Rise of the 2 nd Biological Psychiatry Deinstitutionalization en masse from early 1960s to early 1980s Community Mental Health Centers Act (1963) turmoil in the 1970’s and the publication of the DSM-III (1980)

The Rise of Psychopharmacology

Managed Behavioral Health (“Carve Outs”) Because “supply drives demand” in health care ->

Number of Acute Care Hospital Beds/per 1,000 Residents Source: Dartmouth Atlas of Virginia

Number of Hospital Discharges for all Medical Conditions (DRGs) Source: Dartmouth Atlas of Virginia

Average number of physician visits per patient during last six months of life who received most of their care in one of 77 “best” US hospitals Source: John Wennberg (2005)

Empiricism Driving Managed Care Researchers’ and Insurers’ Conclusions: (1.) Physician practice styles vary considerably, especially regarding diagnoses for which treatment decisions are not driven by consensus on appropriate care and it is not possible to obtain evidence-based guidelines from reading journals or consulting textbooks. e.g., back surgery rates (the #/per 1,000 Medicare beneficiaries ): - 7/per 1,000 in Naples, FL - 2/per 1,000 in Hanover, NH - 4.5/per 1,000 national average (2.) In medicine, supply generally creates its own demand (e.g., # of hospital beds/per capita, technology available, # of specialists/per capita).

Rates of four orthopedic procedures among Medicare enrollees in 306 Hospital Referral Regions ( ) HipFractureKneeReplacementHipReplacementBackSurgery Standardized ratio (log scale) Source: John Wennberg (2005)

Association between cardiologists and visits per person to cardiologists among Medicare enrollees (1996): 306 HRRs Source: John Wennberg (2005)

Association between # of hospital beds per 1,000 residents (1996) and discharges per 1,000 ( ) among Medicare enrollees in 306 HRRs Source: John Wennberg (2005)

Dilemma & Running Debate Type 1 errors (fear of “medical malpractice” cases and “self-medicating”) (person has a mental disorder but is not diagnosed) Type 2 errors (fear of “cosmetic psychopharmacology”) (person does not have a mental disorder, but is diagnosed with one) Kate Russell for The New York Times Sarah Couch, who has bipolar disorder, opposes the effort to force treatment on the mentally ill. De'Nora Hill: "I am living in fear and I want it to end."

Andrea Yates & Post-Partum Depression w/psychosis