56 PSYCHIATRIC TIMES MAY 2015 www.psychiatrictimes.com PSYCHIATRIC MALPRACTICE Defending a whether the hospital and the doctor blessing. On the first day, I spent 55 The dismissal was “with prejudice,” did their jobs. minutes with the patient and on the which was significant. It meant that Malpractice Suit Engineers gave testimony about second day, 25 minutes. The plain- the matter can never be reinstated Continued from page 55 the window—its quality and manu- tiff’s attorney could not harass me against me anytime in the future, for facture. The patient’s sons and wife, about my short notes when he saw any reason. from my lips. I struggled to maintain the internist, the nursing director, those numbers. The following are some lessons I composure during that sad period of and the nurse in charge gave tes­ • My attorney confirmed that the learned from this suit: my life. Often engulfed by tension, I timony. The latter had visited Mr statement “My father likes you; I • The service you have provided is the used the following “system of com- Kulik every hour that night up to 40 will like to bring him to you after one that you document; if it is not fort” to reduce the stress: minutes before he was discovered discharge from the hospital,” was documented, you did not perform it. Whenever I found my shoulders missing. They all said that Mr Kulik made by the patient’s son during Always record the amount of time tightening or my legs aching, I did had been improving, and there were his testimony. you spent with the patient. relaxation exercises, and I talked to no talk or behavioral changes to alert The jury deliberated. I was unsure • Make it a habit to question all pa- myself out loud about accepting the anyone of a problem. When it was whose side made more sense to the tients about suicidality, violence, worst and moving on. When I my turn to take the stand, I was deter- jury and worried about their deci- and adverse effects—and document thought of going to jail, I countered mined to remain consistent in my sion. Finally the verdict came in: the that you did; if they are present, with, “The worst is that I will go to testimony. During the testimony: hospital was found negligent be- document a rational reason for your jail. Well, Gandhi went to jail. If I • I kept a pleasant disposition in spite cause a nurse had seen a faulty win- decisions, actions, or inactions. have to, so be it. Murderers start a of my inner anxiety. dow but did not report it and get it • In your record, use the word “be- new life after incarceration. I will do • I answered in lay language: I used repaired in time. I was found not cause” frequently; it conveys that that too.” I did not realize that I my knowledge about bipolar disor- guilty of negligence. you are reflective and rational. hadn’t broken any laws, and there der, suicidality, and interviewing, I left the building. I wanted to cel- • Dictate records and work hard to was no chance that I could go to jail. and I made sure that what I said did ebrate by shouting with joy; how­ever, improve your handwriting—it is When I thought about losing my not conflict with the hospital chart, I kept the dignity of a doctor. The embarrassing when you cannot read medical license, I told myself, form C (3), and my deposition. family was standing outside in the your own writing. “There are many people who are not • I looked straight into the eyes of parking lot. They saw me coming, the • Be sure that all collateral informa- doctors. They live full lives. I will the lawyers, except when I was son approached me, and he said, tion and its sources are included in open a 7-Eleven store.” My mantra asked to explain to the jury; I then “You are a good doctor, but we had to the record. became, “I will cross the bridge made direct eye contact with the do this. He was our father you know.” • A lawyer is your best friend during when I see the bridge.” jury members. I wanted to yell at them and curse a lawsuit—you are very lucky if you Whenever I felt that I was project- • The plaintiff’s attorney asked, them for wasting 4 years of my life. I get a good one. ing my anger onto my patients, I “Why didn’t you ask Mr Kulik thought that they did not have to • Please read about malpractice to would say, “I am generalizing. It is about suicide?” I explained and en- apologize, but they did. It was my learn precautions that you need to unfair to the innocent others.” I re- acted the inappropriate affect, talk, turn to be gracious. I said, “I under- take and ways to deal with a mal- peated my concept of the serenity and facial expressions of Mr Kulik. stand, but it was very hard on me.” practice suit. prayer so that I could focus on things Thus, I showed the jury that Mr All of them smiled wishing me good- that were in my control: “May I have Kulik was not capable of giving re- bye. I moved on. Dr Malhotra is Clinical Associate Professor the serenity to accept that I have no liable answers to my questions. Eight days later, I received a letter. at Rutgers New Jersey Medical School in control over the outcome of the suit. • I recorded the duration of my con- “Ordered that a judgment be and is Newark. He reports no conflicts of interest Let me have courage to continue my sult and follow-up visit on the hos- hereby entered in favor of the defen- concerning the subject matter of this article. practice, serve my patients, earn pital records. It was my practice for dant, Harish Malhotra, MD, and the money, and prepare for the suit. Let billing purposes and for Medicare complaint be and is hereby dismissed Acknowledgment—I am thankful to the US me have wisdom that the lawsuit is audit. That habit proved to be a with prejudice and without costs.” judicial process for its fairness. ❒ not in my control, but my ability to fight is under my control.” The trial COMMENTARY The attorney invited me to prepare me for the trial. “Do you have time?” he asked. “Yes, it is 2 pm,” I an- swered. He returned, “I did not ask Correcting Psychiatry’s what the time is. Your response should be ‘Yes, I have the time.’ If I ask, ‘What is the time?’ You should False Assumptions and say, ‘2 pm.’ Do not give more infor- mation than what he [the opposing attorney] asks. You may be giving Implementing Parity self-incriminating answers. I will be listening. If there is a fact that you need to clarify, I will ask later.” by Eric M. Plakun, MD (as funders of both care and re- clinical care and implementation of Jury selection was completed, and search), clinicians, hospitals, ac- parity. the trial began in mid-2009. The t is a source of shame for our na- countable care organizations, and plaintiffs had a lawyer, and the hospi- tion that for most Americans in insurers, as well as patients and Psychiatry’s false tal and I (the defendants) had sepa- I need—especially those with se­ families, are key stakeholders. Only assumptions rate lawyers. A couple of days were rious mental illness—the mental the federal government has author- Psychiatry clings to 3 false assump- spent going over the case with the health system is dysfunctional. Pro- ity to convene all of the former, but tions despite evidence to the con- judge to come up with an opening vision of population mental health Washington’s current dysfunction trary, and psychiatrists, our patients statement. The three lawyers agreed services is a complex systems issue makes this unlikely. Nevertheless, and their families, and our nation on the following statement: “Mr Ku- that requires multiple stakeholders we can fix some of the ways the sys- pay a price as a result. The assump- lik jumped out of the window and to work in partnership to improve tem is broken. I will focus here on tions are that: died.” The lawsuit would decide it. Federal and state governments 2 critical areas—the paradigm of • Genes = disease

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• Patients present with single dis­ have been found, and the search for fectiveness of psychodynamic psy- orders and failure rates for our best orders that respond to single evi­ them has been likened to that for the chotherapy and CBT for multiple treatments are high. dence-based treatments Holy Grail. individual and complex comorbid For example, in depression, 78% • The best treatments are pills Meanwhile, Tully and colleagues2 disorders—with the ability to distin­ of patients in the large STAR*D offer us a glimpse of the importance guish therapy responders from non- sample­ presented with comorbidity Genes = disease of environmental factors in depres­ responders on imaging.4 or suicidal ideation that would have Mental disorders are clearly herita­ sion by demonstrating that mothers The assumption that disease is all excluded them from randomized tri­ ble. Molecular genetic research who are depressed during childrear­ about genes and biology does help als; however, these comorbid pa­ teaches us that there are 2 kinds of ing often have depressed adoles­ reduce blame and stigma. Neverthe­ tients had lower response to treat­ genes—those that make proteins cents—whether their children share less, the assumption doesn’t fit the ment and lower remission rates.5 So and those that regulate other genes, their genes or are adopted. Other evolving data, and clinging to it risks if you feel, as many clinicians do, often in response to the environ­ studies of early adversity demon­ crippling our ability to understand that the patients you work with are ment. We hoped that sequencing strate that it is a veritable “enviro- and treat our patients’ problems in sicker than those a drug was tested the human genome would lead to marker,” associated with a high risk nuanced and sophisticated ways that on, you are right about 4 times out identification of the genetic under­ of mental illness, substance use, and attend to biological and environ­ of 5. pinnings of mental disorders, but medical disorders—not just with mental factors in a “both/and” rather Again using depression as an ex­ genes turn out to be rough plans PTSD.3 than “either/or” model. After all, an­ ample, we are learning how impor­ rather than detailed blueprints for Emerging evidence shows us that other way to say “epigenetics” or tant comorbid personality disorders an individual. disease is not simply encoded in “gene-by-environment interactions” are to treatment outcome—espe­ Over 125 relevant genetic loci genes, but that gene-by-environment is “biopsychosocial.” cially comorbid borderline person­ have been identified in schizophre­ interactions (“epigenetics”) are cen­ ality disorder (BPD). The large, nia, which indicates that heritabil- tral in understanding disorders. Yet Patients present with multisite Collaborative Longitudinal ity of this and other psychotic dis­ as a profession, psychiatry has shift­ single disorders that Personality Disorders Study (CLPS) orders is far more complex and mul­ ed toward what former APA presi­ respond to single evidence- concluded that the presence of per­ tifactorial than we expected. Single dent Steve Sharfstein called in his based treatments sonality disorders, especially BPD, nucleotide polymorphisms (SNPs) presidential address the “bio-bio- Our practice guidelines and our ran­ “robustly predicted persistence” of are associated with some cancers, bio” model. Many in psychiatry domized trials assume that most pa­ MDD, suggesting diagnosis and type 2 diabetes mellitus, and inflam­ have moved away from and some­ tients have single disorders that re­ treatment of personality disorders matory bowel disease. Genome- times deride the biopsychosocial spond to evidence-based treatments are essential in treating depression wide association studies of depres­ model. Ironically, this has happened in carefully selected non-comorbid lest it become treatment-resistant.6 sion were unable to find meaningful as the above evidence from genetics patient samples. Yet, clinicians know However, in our focus on the SNPs that illuminate genetic un­ has cautioned us to take environ­ from practice-based evidence what medical model, personality disor- derpinnings of this common disor­ mental factors more seriously. Nu­ the research evidence shows: most der.1 No biomarkers for depression merous studies demonstrate the ef­ patients have multiple comorbid dis­ (Please see Implementing Parity, page 58)

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Implementing Parity prove patient care. Attending to the brain function rather than common orders should be treated either as Continued from page 57 importance of psychosocial or envi- factors across psychosocial treat- inpatients or outpatients, with no ac- ronmental factors also means taking ments that could directly improve cess to intermediate levels of care more seriously the contributions of patient outcomes. (such as residential treatment), ders are underdiagnosed. In DSM- psychoanalytic theory, which has seems inconsistent with parity legis- IV, the most frequent Axis II di­ studied environmental influences Full implementation of parity lation. Would a man with a stroke be agnosis made was “deferred,” and for over a hundred years and, as Mental health care is approved and told that once he was no longer in there is no reason to think this will Nobel laureate neurobiologist Eric funded in a managed care model. need of acute inpatient treatment, he change with DSM-5. Biological tun- Kandel12 stated, offers the most nu- Managed care operates with the had to return to outpatient treatment, nel vision can lead to missing the anced and sophisticated model of same moral imperative as the envi- with no access to intermediate levels reality of clinical complexity and the mind that we have. ronmental movement—focused on of care to begin to learn to speak, interfere with provision of optimal Psychodynamic psychiatry, preserving limited resources. But walk, and resume self-care? patient care. which is the intersection between US managed care companies usu- Despite parity legislation, many general psychiatry and psychoana- ally function as revenue-driven de- insurance companies continue to The best treatments are pills lytic theory, deserves renewed atten- niers of care, especially in mental deny access to care based on such We have overestimated the efficacy tion as part of fixing a broken sys- health. A recent study published in arbitrary exclusions. Successful le- of antidepressants by about a third tem. This does not mean offering JAMA Psychiatry revealed that only gal challenges can establish case law when all studies are considered, and individual psychoanalysis to more 55% of psychiatrists accepted in- fully implementing mental health 75% of antidepressant effect is pla- patients, but it does mean including surance in 2009-2010 compared parity. The good news is that such cebo effect.7,8 The CATIE lawsuits, some as class ac- schizophrenia study showed tions, are under way and are that patients don’t find that gaining traction. the benefits of our pills out- In December 2014, the weigh the adverse effects.9 CBS show 60 Minutes de- Our pills work, but not as voted part of an episode to a well as we might hope, while lawsuit (Wit et al v United the effect sizes of psycho- Behavioral Health) about ar- therapy studies are actually bitrary denial of residential larger than those for medica- treatment to patients with tions.10 In some disorders, the complex comorbid mood, combination of psychother­ eating, and substance use apy and medications is su­ disorders. The segment made perior to medications alone, clear the devastating con­ and when early adversity in- sequences to seriously ill cludes sexual abuse, medica- patients of a pattern of re- tions may add little to the flexive denial of care by outcomes achieved with psy- managed care reviewers. In chotherapy alone.11 another class action suit Psychiatry has reified skills in di- psychoanalytic perspectives in our with 88.7% of physicians in other (Craft et al v Health Care Service agnosis and prescribing medications work with patients. This can occur medical specialties.16 The data fur- Corporation) in March 2015, the as defining characteristics. If we through the practice of “psychody- ther revealed significantly lower judge ruled against the insurance take seriously the message that namic psychopharmacology” that Medicare and Medicaid acceptance company’s motion to dismiss, genes and environment matter in the attends to the meaning effects as rates among psychiatrists than phy- which claimed the lawsuit lacked causation and treatment of disor- well as the neurochemical effects of sicians in other medical specialties. merit because the insurance con- ders, we will need to focus much medications, through knowledge of Low rates of reimbursement for tract specifically excluded residen- more on training in and the practice individual and group dynamics and mental health services; quantitative tial care. The ruling is promising to of psychosocial treatment in psy- defense mechanisms to help psychi- limits, such as annual limits on the plaintiffs because it suggests the chiatry—or surrender our role as the atrists be better therapists and better numbers of sessions or dollars avail- judge sees exclusion of residential most sophisticated mental health cli- treatment team leaders, and through able for care; and non-quantitative treatment as a non-quantitative lim- nicians. You can’t practice what you faithful attention to the authority, limits, such as utilization review it prohibited by parity. Other cases aren’t taught—and can’t teach what agency, and competent voice of the hurdles for prior authorization ac- hold managed care or­ganizations you never learned. However, cur- patient in negotiating an alliance count for much “opting out” of the accountable for other quantitative rently the only place within the APA and in treatment.13 system of care. and non-quantitative limits on care. that stands for the importance of Psychoanalysis is not the only Though understandable given the Their outcomes have the potential psychosocial factors in the causation psychosocial treatment worth our context, these high “opt out” rates to force reform of egregious man- and treatment of mental disorders is attention. CBT, DBT, and other be- are a national embarrassment. The aged care practices that are part of the unfunded APA Psychotherapy havioral therapies, as well as group Mental Health Parity and Addiction what is broken in our mental health Caucus. The Caucus originated in and family therapy, have much to Equity Act (MHPAEA, or parity system. 2014 as a grassroots effort by a doz- offer. Attention to common factors law) offers hope of a remedy, since it Together our voices matter. en APA members concerned that the shared by evidence-based behav- forbids quantitative or non-quantita- Please consider joining “Biopsycho- APA leadership saw no reason to es- ioral and psychodynamic therapies tive mental health care limits more social Matters,” for discussion of is- tablish or fund such a group within offers hope of training those psychi­ restrictive than those in medical and sues such as these at www.meaning its Components. The Caucus has atrists who will never master a man- surgical care. For persons with dia- matterscommunity.org. grown from 12 founding members ualized therapy to better treat diffi- betes mellitus, arbitrary annual lim- in early 2014 to over 200. All inter- cult patients, such as suicidal pa- its in the number of office visits or Dr Plakun is Associate Medical Director of ested psychiatrists are invited to join tients with BPD.14,15 dollar limits for services would be and Director of Admissions at the Austen by contacting me at Eric.Plakun@ There are more issues that must unthinkable, but such limits are of- Riggs Center in Stockbridge, Mass. He was a austenriggs.net. remain unaddressed here, such as ten imposed for people with mental Harvard Medical School clinical faculty Psychiatry would be well advised future directions in diagnosis and disorders. member for over 20 years. Editor of two to rethink its identity and to reaffirm why the NIMH spends the vast Similarly, the managed care the biopsychosocial paradigm to im- bulk of its research dollars studying stance that patients with mental dis- (Please see Implementing Parity, page 60)

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Implementing Parity College of Psychoanalysts and the American be generalized to clinical practice? A STAR*D report. depression and childhood trauma [published cor­ . 2009;166:599-607. rection appears in . 2005; Continued from page 58 College of Psychiatrists. He has been hon­ Am J Psychiatry Proc Natl Acad Sci U S A 6. Skodol AE, Grilo CM, Keyes KM, et al. Relationship 102:16530]. Proc Natl Acad Sci U S A. 2003;100: ored as the Outstanding Psychiatrist in Clin­ of personality disorders to the course of major de- 14293-14296. books, including Treatment Resistance and ical Psychiatry by the Massachusetts Psy­ pressive disorder in a nationally representative 12. Kandel E. Paper presented at: Meeting of the Patient Authority: The Austen Riggs Reader sample. Am J Psychiatry. 2011;168:257-264. American Psychoanalytic Association; January chiatric Society. 7. Turner EH, Matthews AM, Linardatos E, et al. 2011; New York. (WW Norton & Company, 2011), and author of Selective publication of antidepressant trials and 13. Plakun EM, ed. Treatment Resistance and Patient over 40 published papers and book chapters, References its influence on apparent efficacy. N Engl J Med. Authority: The Austen Riggs Reader. New York: WW 2008;358:252-260. Norton & Company; 2011. he has presented widely in the US and over­ 1. Hek K, Demirkan A, Lahti J, et al. A genome-wide 8. Kirsch I, Deacon BJ, Huedo-Medina TB, et al. Initial 14. Laska KM, Gurman AS, Wampold BE. Expanding seas. Dr Plakun is a Distinguished Life Fellow association study of depressive symptoms. Biol Psy­ severity and antidepressant benefits: a meta-analy- the lens of evidence-based practice in psychother­ chiatry. 2013;73:667-678. of the American Psychiatric Association, Past sis of data submitted to the Food and Drug Adminis- apy: a common factors perspective. Psychotherapy 2. Tully EC, Iacono WG, McGue M. An adoption study tration. PLoS Med. 2008;5:e45. (Chic). 2014;51:467-481. Chair of its Committee on Psychotherapy by of parental depression as an environmental liability 9. Lieberman JA, Stroup TS, McEvoy JP, et al; Clinical 15. Sledge W, Plakun EM, Bauer S, et al; Group for the Psy­chiatrists, and founding leader of its for adolescent depression and childhood disruptive Antipsychotic Trials of Intervention Effectiveness Advancement of Psychiatry Psychotherapy Com­ disorders. Am J Psychiatry. 2008;165:1148-1154. (CATIE) Investigators. Effectiveness of antipsychotic mittee. Psychotherapy for suicidal patients with bor- Psycho­therapy Caucus. He is a past member 3. Molnar BE, Buka SL, Kessler RC. Child sexual drugs in patients with chronic schizophrenia derline personality disorder: an expert consensus of the APA Assembly Executive Committee, abuse and subsequent psychopathology: results [published correction appears in N Engl J Med. review of common factors across five therapies. from the National Comorbidity Survey. Am J Public and Past Chair of the Assembly Task Force on 2010;363:1092-1093]. N Engl J Med. 2005;353: Borderline Personality Disorder and Emotion Dys- Health. 2001;91:753-760. 1209-1223. regulation. 2014;1:16. http://www.bpded.com/ Psychotherapy by Psychiatrists. Dr Plakun 4. Lazar SG. Psychotherapy Is Worth It: A Compre­ 10. Shedler J. The efficacy of psychodynamic psy- content/1/1/16. Accessed April 16, 2015. is a Psychoanalytic Fellow of the American hensive Review of Its Cost-Effectiveness. Washing- chotherapy. Am Psychol. 2010;65:98-109. 16. Bishop TF, Press MJ, Keyhani S, Pincus HA. ton, DC: American Psychiatric Publishing, Inc, 2010. 11. Nemeroff CB, Heim CM, Thase ME, et al. Differ- Acceptance of insurance by psychiatrists and the Academy of Psychoanalysis and Dynamic 5. Wisniewski SR, Rush AJ, Nierenberg AA, et al. Can ential responses to psychotherapy versus pharma- implications for access to mental health care. JAMA Psychiatry and a Fellow of the American phase III trial results of antidepressant medications cotherapy in patients with chronic forms of major Psychiatry. 2014;71:176-181. ❒ CLINICAL Intellectual Disability and Psychiatric Comorbidity: Challenges and Clinical Issues

by Kimberley Kendall, MBBCh and dividuals with ID can experience the content of this psychopathology tive attributional style and lower self- Michael J. Owen, PhD, FRCPsych communication difficulties that vary can differ significantly (see Case esteem. We have found that because from problems expressing psycho- Vignettes for examples). As a result, of the often challenging nature of ntellectual disability (ID) is the logical experiences to being unable the presentation of a comorbid psy- diagnosing depression in individuals impairment of general mental to produce speech. As may be ex- chiatric disorder in this group is of- with ID, clinicians frequently find I abilities,­ which affects an individ- pected, this results in an under- ten atypical. Be alert to this when themselves relying on the biological ual’s functioning in everyday life. reporting of psychiatric symptoms.3 conducting assessments. symptoms of depression for diagno- According to DSM-5, ID has an im- Clinicians must be aware of this and sis: sleep and appetite disturbance, pact on 3 broad domains in a per- place great­er emphasis on observ- Affective and anxiety poor concentration and memory. son’s life: conceptual (eg, language ing the individual and on obtaining disorders Mayville and colleagues6 found that and memory), social (eg, empathy, collateral history from family and Affective and anxiety disorders occur persons with depression and ID had social judgment), and practical­ (eg, care staff. in individuals with ID at a rate of a lower food intake than those with personal care, money management).1 There can be a tendency to attri- around 5.7% and 3.1% respectively.2 ID who were not depressed. Individuals with ID have a higher bute any behavioral/psychological In addition to the classic symptoms A review of rapid cycling bipolar risk of psychiatric disorders than in- disturbance to an individual’s ID seen with these disorders, their atypi- affective disorder found that hyper- dividuals with intelligence in the (known as diagnostic overshadow- cal presentation can include features somnia occurred in 70% of sleep- normal range: prevalence is as high ing).4 This significantly increases the such as aggression and self-injurious disturbed depressed patients with as 40.9% based on clinical diagnosis risk of missed diagnoses. Individuals behavior. ID.7 There is little literature on the and 15.7% based on DSM-IV-TR.2 with ID often have the same form of In a study on depression symp- presentation of mania in individuals When specific ID diagnostic criteria psychopathology (eg, auditory hal- toms in individuals with ID, Es- with ID. In their review of rapid cy- are used (diagnostic criteria for psy- lucinations) as those with intelli- bensen and Benson5 found that those cling bipolar affective disorder in chiatric disorders for use with adults gence in the normal range. However, with MDD and ID had a more nega- persons with ID, Vanstraelen and with learning disabilities [DC-LD]), Tyrer7 found that mood states were the most common comorbid psychi- generally described in terms of ob- atric disorders are problem behavior servable behavior rather than affec- (18.7%), affective disorder (5.7%), tive state. They found that signs of autism spectrum disorder (4.4%), manic episodes typically included psychotic disorder (3.8%), and anxi- insomnia, increased activity, pres- ety disorder (3.1%).2 sured speech, and agitation. Problem/challenging behavior is Because of the lack of random- heterogeneous and its assessment ized controlled trials for the man- and management are beyond the agement of anxiety, depression, and scope of this article. The focus here bipolar affective disorder in persons is on the comorbid presentation of with ID, recommended pharmaco- affective and anxiety disorders, psy- logical options do not differ signifi- chotic disorder, and autism spectrum cantly from those for individuals disorder. with intelligence in the normal range. It is worth emphasizing that Challenges efforts should be made to identify Specific challenges in the field of ID and manage potential precipitating can make the diagnosis of comorbid and perpetuating factors (eg, change psychiatric disorders difficult. In­ © ABSTRACT/SHUTTERSTOCK.COM in environment, disrupted sleep).

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