At Last, Help for Afflicted Brains in Afflicted Bodies

The revolution churning the American health care system has left many physicians feeling that their relationship with their patients has been torpedoed, and they themselves personally attacked. Under managed-care policies most doctors spend less time with each patient, order fewer laboratory tests, schedule fewer follow-up visits, and tend to see sicker patients with more complicated problems. Specialists are left with cases that cannot be sent to primary care physicians, nurse practitioners, or physicians’ assistants.

Psychiatry has been no exception. Managed care, like some seismic shift in the natural environment, has been pushing psychiatrists into new niches where their special advantages may aid survival. Some are specializing in treating disorders resistant to standard treatments (“refractory disorders”). Others are focusing on patients with the most severe mental illnesses. For example, psychiatrists who once treated routine depression now specialize in patients suffering frequent, severe episodes of depression that do not respond to commonly used drugs. In traditional office practice, many psychiatrists have become prescription managers. A psychiatrist may see a patient for an evaluation, prescribe medication for depression, and then schedule a “med check” a month or two later. If the patient has improved, visits may be once or twice yearly.

Under this pressure, some psychiatrists are turning their attention to another type of patient, the patient who combines physical and mental disorders. The transition will be difficult, with many challenges along the way, but ultimately, I believe, psychiatrists and patients alike will benefit.

First, consider this trend just from the point of view of the psychiatrist’s managed-care dilemma. At least for now, psychiatrists who specialize in patients with physical and mental disorders are relatively free from interference by managed-care companies. For one thing, patients with combined physical and mental disorders, because of the medical side of the treatment, must be managed by physicians, not other health care professionals.

But there is also less interference in the treatment itself because of the nature of hospital-stay regulations. Under these regulations, patients with typical psychiatric disorders are reviewed every day or two while hospitalized. Nurse managers decide, based on written criteria, if the patient may remain in the hospital or must leave (or, as these managers like to put it, “Your doctor decides whether you stay; the company just won’t pay for it.”) These reviewers, however, are not adequately prepared to evaluate patients with both physical and psychiatric disorders; nor have standards been set (as yet) that dramatically shorten the stay of such patients. Some studies have concluded that evaluation and treatment of the psychiatric disorders of patients with physical illness may reduce the length of hospitalization and the cost of care, ¹ but not all studies have agreed.²

How strong is the trend among psychiatrists to specialize in patients with these combined disorders? Some indicators are membership in professional societies, training programs, and research.

• Membership in the American Neuropsychiatric Association, devoted to patients with combined neurological and psychiatric disorders, has more than quadrupled from 126 in 1991 to 550 today.³
• Training programs have burgeoned. In 1993 there were just five U.S. training programs, with a total of 19 residents, leading to board certification in both internal medicine and psychiatry. Now there are 28 programs with 185 residents.⁴ We have seen similar growth in family practice and psychiatry residency programs, spurring their professional societies to seek subspecialty certification from the American Board of Neurology and Psychiatry in “consultation liaison psychiatry” (i.e., psychiatric consultation about patients on general hospital medical wards) and neuropsychiatry (i.e., care of patients with both neurological and psychiatric disorders).
• New medicine-and-psychiatry inpatient units are appearing at community hospitals as well as at university hospitals.⁵ These combined units function at 90 percent occupancy levels in institutions where the occupancy rates of separate psychiatry services and internal medicine services have plunged. A patient’s alcoholic hepatitis and suicidal depression, or his lung cancer and incapacitating panic disorder, can be adequately treated only in a medicine-psychiatry unit. As our population ages, there are more of these patients.

“Ground Cover”

How successful have psychiatrists been in developing this new brain-body niche? The answer depends on your yardstick.

The number of research publications on patients with combined disorders has grown over the past 14 years. There has been a dramatic increase in publications dealing with depression and anxiety disorders in patients with physical illness, compared with the increase in publications dealing with schizophrenia, bipolar (manic depressive) disorder, and anxiety disorders in patients with no associated physical illness. There are now eight times as many publications on anxiety disorder in patients with physical illness, and five times as many publications on depression in patients with physical illness, as there were 14 years ago. The increase is substantially greater than the increase in publications related to traditional, non-combined psychiatric disorders. The difference, however, is relative. There has been increased research on depression and anxiety among patients with physical illness, but publications on traditional psychiatric disorders are still appearing at a substantially higher rate.

Today a psychiatrist can find articles on mental disorders that may accompany cancer, heart disease, respiratory disorders, endocrine and metabolic disorders, gastrointestinal disorders, immunological disorders, and musculoskeletal disorders. The problem is that there are so many physical disorders that our knowledge of the psychiatric problems linked with any particular one can be scant. Consider brain tumors. As common as they are, our knowledge of the psychiatric disorders associated with them is extremely limited. Even taking a common psychiatric disorder, such as depression, and a common type of nonfatal tumor, such as a meningioma, I could (with one exception) find only anecdotal case descriptions in the medical literature. One study did examine depression in 32 meningioma patients, but the investigators used a depression scale (a general measure of overall depression) rather than standardized diagnostic criteria.⁶ They could not break down how frequently meningiomas are associated with new-onset depressions, nor the cause, clinical manifestations, natural course, or clinical pathological correlations of new-onset depressions. Nor is there literature on the big question: how to treat these disorders.

Similarly, we know little about psychiatric disorders associated with peptic ulcer, rheumatoid arthritis, retinal degeneration, deafness, brain injury, pancreatic cancer, amputations, liver disease, and amyotrophic lateral sclerosis—to name only a few. The controlled-treatment trials that could answer our questions are time-consuming and costly, and so rarely done. (Before my colleagues who study these problems protest: My point is not that we know nothing about these disorders, but that what we don’t know is greater than what we do know.) J. L. Levenson has characterized psychosomatic research as producing a “ground cover” rather than a “hedge” of knowledge.⁷

What We Don’t Know

Few scientists have been interested in combined mental and physical disorders. Residency training programs have tended to turn out psychiatrists who see depression, schizophrenia, and anxiety disorders as psychiatry’s “mainstream.”  For years the attention devoted to research on traditional psychiatric disorders has swamped the attention directed at psychiatric disorders in the physically ill.

Scientists who work in this area face two basic problems. First, there are so many common physical disorders that linking psychiatric disorders to each one, and establishing practice guidelines, is an enormous task. Second a large number of psychiatric disorders can occur with a given physical disorder.

Investigators examining psychiatric aspects of physical illness have tended to focus on depression. This is understandable, given the high frequency of depressive disorders in the general population⁸ and the even higher frequency in patients with physical illness,⁹ but it has led to neglect of many other brain-body interactions that are clinically important: anxiety disorders, somatoform disorders, personality disorders, psychotic disorders, and bipolar disorders.

Take mania. Several studies have linked mania with physical disorders such as stroke or traumatic brain injury, but there is no systematic study of mania’s clinical course or treatment. Similarly, although the existence of schizophrenia-like syndromes among patients with brain infarction, tumor, or trauma has been reported, systematic studies and controlled-treatment trials have not been done. There are also mental disorders unique to brain damage:

• anosognosia (seeming unawareness of physical impairment even in the face of evidence to the contrary)
• catastrophic reactions (brief but explosively angry outbursts generally associated with performance failure and reduced intellectual capacity)
• apathy (lack of drive and motivation)
• disturbance of prosity (inability to recognize emotional intonation in language or emotional expression in facial features)
• pathological laughing or crying (uncontrolled emotional display without the associated underlying emotion)
• indifference reaction (seeming unconcern about associated impairments)
• disinhibition syndromes.

Some of these have now been studied. For example, we have controlled studies showing that antidepressant medication can reduce pathological crying in multiple sclerosis¹⁰ and stroke.¹¹

These examples suggest what a range of emotional disorders can occur with a single physical illness such as stroke. When you think about how many physical illnesses there are, the enormity of the job of ascertaining the symptoms, progression, and treatment of mental disorders that may accompany them is all too obvious. Psychiatric training programs, research fellowship programs, and government and private research money should target this problem.

A New Practice Paradigm?

How will the shift toward patients with physical-mental disorders change psychiatry? I can imagine a time when a typical psychiatrist’s practice might be half traditional psychiatric disorders and half patients with physical-mental disorders. Caring for the latter will require psychiatrists to collaborate with internists, orthopedists, gastroenterologists, neurologists, and others. This may move psychiatrists away from traditional psychiatric care, of course; but it will move them closer to other medical specialists and to the way most medical specialists work.

The biggest impact may be on training. I expect a further increase in the popularity of combined training programs, such as internal medicine and psychiatry, family medicine and psychiatry, pediatrics and child psychiatry, and neurology and psychiatry. Training in general medical practice may become a bigger part of our psychiatry residency training programs. By the same token, as knowledge of patients with physical and mental problems increases, the training of other specialists and of generalist physicians will include more about these disorders. Physicians will become attuned to recognizing and seeking consultation for them.

New knowledge tends to influence education. In 1984 my colleagues and I published a study of treating depression in patients with stroke.¹² This increased interest among psychiatrists, neurologists, rehabilitation specialists, and primary care physicians in recognizing and treating post-stroke depression, and the potential complications of doing so. Psychiatry and neurology residency programs began to teach residents how to recognize and treat post-stroke depression, a treatment now fairly common. Similarly, treatment trials targeting pathological laughing and crying and depression in Alzheimer’s and Parkinson’s diseases have led to training in the management of these conditions. With further gains in knowledge, we should see still more teaching related to the care of these patients. The growth of continuing medical education programs in geriatric psychiatry shows how an expanding knowledge base (in this case about aging) can stimulate practitioners to hone their clinical skills.

How will shifts like these affect the mental health professionals who work with psychiatrists? My guess is that we will continue the process already started. Triage nurses at managed-care companies send complicated cases with multiple episodes of illness to psychiatrists; they send patients with marital problems or adjustment disorders to social workers or nurses. They will continue to send traditional psychiatric patients to lower-cost allied mental health providers (social workers, counselors, physicians’ assistants, and advanced registered nurse practitioners) for psychological and pharmacological management, eroding the traditional practice of psychiatry.

Explaining Away Mental Disorders

Let us pose another question. If in the future psychiatrists will be treating more patients with combined physical and mental disorders, who is treating these patients now? The literature suggests that many of these patients simply do not receive treatment for their mental disorders. A study published in 1992 showed that 10 of 15 stroke patients in a medical rehabilitation ward were depressed (as diagnosed by psychiatric interview), but none was recognized by the rehabilitation team as having a significant clinical depression.¹³ Their depressions were missed because a mental-status exam was not done or because the few signs of depression were considered “understandable”—a natural reaction to impairment.

Other studies show that this is typical. Physically ill patients with psychiatric disorders will begin to be identified when internists and neurologists are more aware of these disorders and include consulting psychiatrists on medical wards to help identify and refer these patients. One result may be an increase in patients seeking psychiatric care; another may be a mixture of patients very different from the one psychiatrists traditionally have seen. Instead of patients with adjustment disorders, first episodes of depression, or dysthymic disorders, we will see patients who combine Parkinson’s disease with depression, or heart failure with panic disorder.

Did psychiatrists simply overlook patients with combined disorders for all these years? The medical literature actually suggests that these patients were being identified by psychiatrists almost a century ago. Early psychiatrists such as Emil Kraepelin¹⁴ and Adolf Meyer¹⁵ recognized that physical illness was often associated with mental disorders and left many early reports. The real problem may be that physicians and family members do not realize that mental disorders are abnormal even in the context of physical illness.

There is a tendency to explain the mental disorders of patients who also have physical problems as a psychological response to their physical disorder or to a grave prognosis associated with it. Again, stroke is an example. There are neurology textbooks explaining that, until the stroke victim lives through his depression, he will not adequately adjust to the lifestyle limitations imposed by stroke. Is it surprising that families and physicians see depression as psychological and dismiss it as part of the recovery process?  I saw a patient, a well-known history professor, who had suffered a stroke two years earlier that left her unable to speak coherently or write. Her severe depression was “understood” by the family and treating physician. Of course, she would not get over the depression until she made progress in speech rehabilitation, which she practiced three to four times a week. In fact, however, after I treated her with an antidepressant, her mood improved dramatically. She was far more motivated to continue speech therapy.

Good for Psychiatrists? Good for Patients?

Managed care has been reshaping psychiatric practice for 20 years. There may be no going back to the days when psychiatrists provided psychotherapy to patients with depression, adjustment problems, and other “neurotic” conflicts. The anger that psychiatrists feel over this intrusion is evident. For example, members of the American Psychiatric Association recently elected a president from their rank and file who had no backing by the Association’s administration, but who ran on a platform of fighting managed care at all costs.

One lever used by managed-care companies has been the lack of evidence that patients treated for adjustment disorders, neurotic problems, and even mild to moderate depression do better with a psychiatrist than with a nurse practitioner, social worker, or psychologist. An evaluation of psychotherapy versus pharmacotherapy in treating depression found that neither the type of psychotherapy nor the background of the psychotherapist made any difference.¹⁶ Let me be clear. There are many examples of abuse in managed-care decisions based on relative costs of treatment. Patients are forced out of the hospital before they can safely go home. Many relapse into illness because they are denied adequate follow-up care. On the whole, however, the shift from psychiatrists to less costly mental-health professionals has not measurably hurt patients’ ability to get appropriate treatment for their mental disorders.

In contrast, patients with combined physical and mental disorders have frequently gone untreated for their mental disorders. Often these are elderly patients who have little experience with mental-health professionals, no previous history of psychiatric disorder, and a belief that their depression or anxiety cannot be treated because it is related to their physical limitations. They may be right about the cause of the mental disorder, but that does not mean it cannot be treated. The patient whom I described earlier, with loss of language following a stroke, went for year without being evaluated or treated—but eventually treatment worked well. Another patient that I saw about a year after her stroke was a housewife who had been socially active with her retired husband, but following her stroke suffered uncontrollable episodes of crying. They were easily triggered but did not reflect her mood. She was so embarrassed that she refused to go out, accepting a lonely life at home. With treatment, the episodes virtually stopped, and she resumed her social life—but only after her year of tragic isolation.

“The Greatest Beneficiaries”

I am convinced that the change now under way will benefit psychiatry and medicine as a whole. Psychiatrists will focus on conditions for which their medical training makes them the appropriate care giver. Indeed, we may discover that many mental disorders that psychiatrists traditionally treated are actually combined physical and mental disorders. Magnetic Resonance Imaging has shown that elderly patients with their first depression often have small vascular infarctions that affect the gray or white matter of their brains. We now identify these disorders as “vascular depressions,” recognizing that the patient has suffered recurrent strokes as well as major depression. Other disorders, such as anxiety, may someday be understood as the result of genetically produced physical illness.

I predict that psychiatry will continue to turn toward patients with combinations of physical and mental disorders, learning more about the nature, clinical presentation, and treatment of these disorders. Psychiatrists will move closer to other specialties in medicine, putting them on firmer footing in the medical arena. We will alter our training programs and stimulate psychiatrists already in practice to increase their knowledge in areas of physical medicine. The greatest beneficiaries, however, will be the many patients who have borne the burden of both physical illness and psychiatric disorders and who may at last get the care they deserve.