PHILADELPHIA REFLECTIONS
Musings of a Philadelphia Physician who has served the community for six decades

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SECTION TWO: Hidden Economics of Healthcare
Here are samplings of the reasons Healthcare Reform still isn't going anywhere.

Psychiatry: Scientific Frontier, or Stormy Seas ?

Although scientific news about healthcare research is mostly pretty good, a storm may be approaching in psychiatry. Not only are that specialty's finances in disarray, but as the rest of the profession steadily conquers its share of diseases, lack of progress in psychiatry becomes more noticeable. Large sums are donated and granted to repair this gap, in a typically American approach to such obstacles. Maybe it is too soon to expect dramatic results. President John Kennedy once learned thorazine was helping psychotic people go home from state mental hospitals, and put that information alongside the painful cost of maintaining 500,000 rather decrepit beds. Effectively, he closed most of them. It was well intentioned, but too quick.The important thing to notice was how very many psychotic patients there were, and therefore how big a job it entails.

{top quote}
Psychiatry was ruined, first by Freud, and then by the DRG. {bottom quote}

Around 1965, the recreational drug scene along with its flower children and colorful activists unexpectedly hit us, trailed by optimistic news reports that heroin really wasn't so bad, LSD might have therapeutic potentials, and marijuana might even be beneficial compared with alcohol. Some of these contentions have been scientifically dismissed, but one discovery was greeted with delight by school children: marijuana was about the same as alcohol, but the smell on the breath didn't give it away. For a while, it was unclear whether drugs made you psychotic, or psychotic people were attracted to drugs; it's still not entirely clear. The city police, who were dragooned into maintaining law and order amidst this commotion, resorted to the only resource they had, which was the local jails. The public agreed, perhaps hoping to scare the miscreant children, and passed laws about speedy trials for drug offenders, mandatory jail sentencing, and mandatory long sentences. The prisons filled up, older prisoners taught newcomers some tricks, and it was not long before the prison systems and the school systems were destabilized. We closed the snake pits and skid rows, all right, but we gave ourselves a drug problem, a prison problem, and a school problem.

The simultaneous development of a problem we had never quite seen before, at least to anything like a similar degree, caused a few reflective people to remember we had always had a large segment who were mentally unstable. It was a tenth of the population, possibly even a fifth. My pristine suburb spends 8% of its budget on "Special" education. Some of this was indeed new. Alzheimer's disease is one of the outgrowths of the advancing longevity we are so proud of. Women who delay having children are especially prone to deliver babies with Down's syndrome of mental retardation. Women are now going to work instead of tending children and aging parents, forcing these patients more into the open. The mechanization of warfare means more rejections for mental inferiority, because soldiers need to be smart to be trusted with such weapons. So it's hard to know whether there is more mental disorder than before, or whether it has always been there, and is emerging from the shadows. In any event, we must newly face a very large segment of the population who are unemployable, and as they age, are adrift even from the discipline of regular employment.

The medical profession, preoccupied with its more usual tasks, woke up to this situation in odd little ways. One strange alert we might have noticed was the woeful inability of any medical coding system to define a relationship between psychiatric diagnosis and its treatment. In almost every other sort of condition, the diagnosis alone conveyed a pretty good idea of what the disease would cost; not in psychiatry. That was true within SNOmed and ICDA, the two main diagnostic codes for all fields of medical diagnosis, as futile efforts to squeeze it into DRG were to prove. It is also just as true within DMS (Diagnostic and Statistical Manual of Mental Disorders), the codes the psychiatric profession struggled to devise as a codebook of legitimate psychiatric conditions. It's definitely possible to construct an organized list of psychiatric diagnoses, using numerical codes instead of words. But it defies the imagination of everyone who tries it, to establish any reproducible connection between psychiatric diagnosis codes and the duration, cost or efficacy of treatments. Especially efficacy of treatments, without which little progress can be expected.

In the future, expect to hear less and less about surgery and medicine. Lots of people get sick, but sick with fewer different diseases. Research currently only seems to need to devise four or five cheap effective cures. But with psychiatry, the research is powerfully inhibited by the thick impenetrable skull, the lack of resemblance between the brain's anatomy and its functions, the extreme dangerousness of surgical experimentation, and the lack of any good idea how to connect the brain with the mind. We have a long, and expensive, way to go.

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