there is love of humankind, there is also love of the art of medicine." *
The goal in treatment is to stop and reverse the pathological vicious cycles. The better we understand the sequence of events that causes and perpetuates the pathological process, the more options we have for treatment. Theoretically, we can intervene at any stage in the sequence of events that causes and/or perpetuates the disease process.
Most psychiatric illness is a complex vicious cycle with many entry points and, likewise, many exit points. To some degree, problems caused by environmental factors are often treated by environmental treatments; neurochemical problems by neurochemical treatments, etc. However, this is not always the case. Any safe and effective treatment that breaks the vicious cycle of disease may be implemented regardless of what initiates or perpetuates the disease. All situations are unique and individualized treatment plans are always required.
All treatment decisions are a complex, multi-system, weighted judgment attempting to predict and compare the benefits and risks of treatment against the risk of disease. Which is greater? No one can guarantee 100% predictability.
Prior treatments were crude when compared to those implemented today. The goal is to intervene in the most limited and effective manner. For example, in psychopharmacology, the older medications had many unwanted side effects in order to achieve a more limited therapeutic effect. The newer treatments, by comparison, have a more limited effect. To compare to a military model, the older treatments are like the carpet bombing of Dresden, while newer treatments are more like the smart bomb that was dropped down the chimney of military headquarters in the Gulf War. Although a highly targeted intervention is the goal, it is never fully achieved.
As a result of new technology, much progress has been made in the past few years to improve the treatment of mental illness. This improvement, including the new broad-spectrum psychotropics, has resulted in a reduced census in our psychiatric hospitals similar to the reduction in state hospital censuses after the release of Thorazine in the 1950's. Stigma, lack of awareness, health care system failures and financial barriers are the main obstacles to treatment today.
Once it is determined that treatment is needed, who has the responsibility and power to select the treatment option? Clearly, there should be a system of proportionate responsibility and power with those who hold the greatest responsibility having the greatest power in the treatment decision-making process. From an ethical standpoint, therefore, the patient (or the patient's caretaker) should have the greatest responsibility, second is the expertise of the treating physician and third are ethically accountable regulators.
In some deceptively complex health care systems, the patient and treating physician still hold the responsibility but lack the power to make effective treatment decisions. The entity (or individual(s)) who hold this power may be biased by various financial intents and may not put the interests of the patient first. In such cases, "therapeutic equivalents" and/or "therapeutic substitutions" denial of treatment or reduction of treatment, are used at the expense of the patient to improve profits for the "managing" company.
The term "therapeutic equivalent" implies the substituted therapy is equivalent, but is it? Given the complexity of disease, no therapy is truly equivalent. The very use of this term is fraudulent if it cannot prove the "therapeutic equivalent" is totally equivalent in every respect, in any given situation. "Therapeutic substitution" is a more honest term since it does not imply the substituted therapy is equal. The patient should hold a proportionate power and responsibility in making such decisions.
Many crude and rough treatment algorithms have been proposed and are sometimes used. If they are recognized to be teaching tools and very rough guidelines they may have value. If, however, they are used as a closed-system treatment protocol to override the uniqueness of the situation or sound judgment, they become reckless, negligent and dangerous. Patients and caretakers should use caution when being referred to or by an entity influenced by bias.
Access to health care is maintained by constant vigilance. It is impacted by many other issues such as trust that health care will be adequately controlled by medical ethics, a guarantee of confidentiality, protection of individual freedom, cost-effectiveness, protection against fraud and standards to maintain quality of care. Any effective plan must embrace all of these areas.
There has been a failure to provide an adequate plan in our country. As a result, profit-driven systems such as managed care have proliferated and have clearly failed to meet the needs of our society. Capitated plans are a slight improvement over managed care because the plan administrators have a greater ethical commitment. However, they are limited potentially since there is an inherent conflict of interest between the needs of the patient and that of the provider.
Combinations of medical savings accounts, fee for service, traditional indemnity and other plans continue to have potential. In my opinion, proportionate responsibility is a critical issue. All who participate must have proportionate levels of responsibility and power to maintain an adequate balance of power and accountability in the health care system. Parity of mental health coverage is also critical. If we fail to propose an effective health care plan, others have, and will continue to propose plans that are self-serving.
As a member of the American Psychiatric Association Committee for Universal Access, I am gathering information relevant to health care access. I am looking for ideas and advice for the construction and proposal of a fair and effective health care plan. This is not a forum for grievances but an opportunity for you to participate in building a health care plan that is ethical and cost-effective, with the interests of the patient first.
The amount of resources allocated from the total budget towards health care is dependent upon our perception of the value of life. Since we, as a society, agree to pay for our own and other's health care, how can we be assured this money is well spent on true health care rather than being wasted on bureaucracy and fraud? What is a fair and effective system to allocate health care dollars?
The patient and/or their guardian have the authority to consent to treatment decisions. In making these decisions it is necessary to listen carefully to the opinion of the treating physician. In all medical decisions, no one has any total ability to predict the future. All decisions are based upon a weighted decision comparing the risks of treating vs. not treating. Untreated or inadequately treated illnesses may sometimes have complex and far reaching effects. Conversely, any treatment that may have desirable effects may also have undesirable side effects as well. Since everyone is different, various treatments may have a therapeutic or undesirable side effect in different individuals. Studies are preformed to assess safety, tolerability and therapeutic effects in a significant number of patients. Since no two people are exactly the same, no prior study can totally predict a response in any given individual. Occasionally some side effects are evident only after many have been treated for long periods of time. There are many sources of information, some being more reliable than others. In considering treatment options and consenting to treatment decisions, feel free to investigate all sources of information. One source of medical information is the peer reviewed medical literature, some of which is available through the National Library of Medicine at http://www.ncbi.nlm.nih.gov Other sources of information include consulting other physicians or practitioners, the Physician’s Desk Reference, the FDA, the Internet and various media outlets. It is important to note that most medical knowledge is yet to be discovered, and there is a considerable amount of conflicting information within the current medical literature and other sources of information.
For a variety of reasons, there has been an increasing motivation for individuals and groups to impact the physician patient relationship. This has sometimes resulted in a variety of media reports, insurance company policies, bureaucratic obstacles, privacy intrusions and various high profile lawsuits.
It is suggested all this information be approached in a manner which recognizes the potential bias from each source in an effort to maintain scientific objectivity. You have the ultimate authority in making decisions regarding your health. Open communication with your treating physician regarding beneficial as well as undesirable effects is encouraged to help achieve a better outcome.
Robert Bransfield, MD, FAPA