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Authorization Request for New Treatment Approach

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Blog by Steve Sobel

Dear Health Insurance Bureaucrat:

Ms. Anne Derstoode has now failed several attempts to treat her mental illness.  As indicated in records we have previously submitted, her diagnosis is probably major depressive disorder with psychotic features. However, the differential diagnosis includes schizophrenia, schizoaffective disorder and possibly posttraumatic stress disorder as it is unclear if her paranoid thinking is genuinely psychotic in nature or more plausibly attributable to the horrific childhood abuse and later traumatic events she may have suffered. A case could also be made for a diagnosis of generalized anxiety disorder or adjustment disorder (we try to avoid using that diagnosis as there are few approved reimbursable treatments for it) or perhaps a combination of all of the above. Of course, as we know, these labels have little meaning as we haven’t the foggiest idea of the underlying etiology or whether we are “carving nature at its joints.”  On top of that, what we label “schizophrenia” or “depression” is most likely a collection of diseases that we will someday, hopefully, better understand. That being said, one needs a working hypothesis, so let’s go with psychotic depression.

Esteemed bureaucrat, allow me to detail the treatments thus far provided to Ms. Anne Derstoode. As would be expected, we initially utilized a rather mild treatment, hoping to affect a cure without exacting a price of severe side effects. Thus, we initiated rotational therapy by spinning the patient in a chair with ropes attached to each leg. Clearly, this treatment is supported by expert opinion. Namely, the physician/scientist Erasmus Darwin, grandfather of Charles, developed the approach. Furthermore, Benjamin Rush, the father of American psychiatry, author of the first major psychiatric textbook in the U.S., Surgeon General of the Continental Army, not to mention a cosigner of the Declaration of Independence and great humanitarian, espoused this technique as well (though of course he considered bleeding of patients and administering mercury to be still more  effective approaches). Improving brain circulation and reducing brain congestion with the aid of centrifugal force has face validity and makes eminent sense. Ms. Anne Derstoode did, in fact, appear somewhat less aggressive, but simultaneously developed an inexplicable fearfulness. In addition, she strenuously objected to the dizziness, vomiting and loss of bladder and bowel control encountered at therapeutic spin rates. Furthermore, most of her symptoms persisted despite an adequate therapeutic trial.

The treatment team next implemented a program of hydrotherapy, modeled on that employed by the London Asylum for the Insane. In collaboration with our local fire department (which allowed us to keep costs to a minimum) we strapped Ms. Anne Derstoode to a wall and blasted her with water from a fire hose. Unfortunately, this intervention appeared to exacerbate her level of agitation. We, therefore, switched to hydrotherapy in a steam cabinet with no better outcome. Next, we kept her body submerged in a warm bathtub overnight (allowing bathroom breaks, of course, as this is, after all, a fundamentally humane and gentle treatment). As best as we could ascertain, Ms. Anne Derstoode continued to meet full criteria for the diagnosis of psychotic depression. Persecutory delusions were manifested by ranting vitriol such as: “you’re trying to kill me” and “you’re not even real doctors.” Her very appearance transformed before our eyes, as her expression resembled that of a deer in headlights.

At this point in her illness, we realized heroic measures were required to deal with her level of desperation. We decided to turn to a tried-and-true method vetted by the experience of mental health providers throughout the ages—trepanation. By drilling a burr hole in our patient’s skull, it would logically follow that her brain circulation and overall well-being would improve. We, of course, reject earlier theories regarding the mechanism of action. Specifically, we considered it mere speculation that demons trapped in her brain could escape through these holes. That strikes us as patently unscientific. We are not sure if trepanation is a covered expense by your insurance plan, but, fortunately, the patient was willing to pay out of pocket. This empirical treatment is endorsed by colleagues worldwide e.g. Neolithic providers in France as well as pre-Inca and Inca mental health practitioners. We perused the specific instructions given by such experts as Hippocrates and Galen regarding the proper technique for trepanation. We did not feel it necessary to utilize the Incan ceremonial knife—the tumi, as we were able to create perfectly fine burr holes with our existing surgical tools. We concluded this would be preferable to the technique employed by the librarian Bart Hughes, who performed trepanation on himself using his Black and Decker power drill in 1965. Some of our local colleagues expressed skepticism about this treatment, but we ignored their obsession with evidence-based medicine and their therapeutic nihilism. Skepticism may be hazardous to the health of our patients.  True, there is scant support in the recent professional literature, but not everything can be gleaned from textbooks. We must also rely on our own experience and the practical wisdom of others, which sometimes outpace science. Practicing medicine is not as simple as following a recipe in a cookbook. Innovative approaches are demanded by our patients presenting in extremis. In this case, however, the procedure was complicated by a pesky infection. Thanks to the competence and professionalism of the treatment team, our patient did recover from the infection, but her psychiatric symptomatology had not abated.

At that point in her treatment, Ms. Anne Derstoode became rather oppositional and even more depressed.  Before we could propose the option of insulin shock therapy, as developed by Dr. Manfred Sakel in 1927 in that center of culture-Vienna, the patient actually self-administered a high dose of insulin which she obtained from the supply of her diabetic mother. She did so due to her disappointment about the unfulfilled promise of trepanation.  Ironically, she did not realize she was administering such an effective treatment. She did not die as she had hoped, but nor did her depressive symptoms show any sign of budging.

Lobotomy would have been the logical next step in our treatment algorithm. We discussed the potential benefits of this procedure and pointed out that Dr. Egas Moniz was awarded the Nobel Prize in Physiology and Medicine in 1949 in recognition of his development of this medical technological breakthrough (though presumably the patient who shot and paralyzed Dr. Moniz had been a nonresponder to prefrontal leucotomy).  We educated the patient about the prefrontal leucotomy technique. We explained that disconnecting her frontal lobe would free her of any disturbance in mood related to its malfunction. Once again, a simple yet elegant theory that makes intuitive sense. Regrettably, Dr. Walter Freeman’s lobotomobile is no longer in service, but his method of inserting a small ice pick through the eye socket and wiggling it to and fro seemed easy enough to replicate. Of course, we mentioned the possibility of becoming incapacitated due to cognitive impairment and the risks of cerebral hemorrhage and infection as well as the 15 % mortality rate. Ms. Anne Derstoode adamantly refused this high-tech medical treatment despite being informed that even the Kennedy family had thought it appropriate for Rosemary (though in her particular case it left her mentally incapacitated and unable to speak intelligibly).

As you know only too well, wise bureaucrat, we cannot expect our patients to always make rational decisions. Still we strive to avoid paternalistic approaches in medicine. Instead, we must try to formulate a collaborative treatment plan with our patients. Thus, we offered her another option from our armamentarium of effective treatments and sought to meet her where she was, so to speak. Namely, with your blessing and generous reimbursement, we prescribed psychotropic medications. Surely, the brain is an organ like the kidney or the heart and mental illness is a medical illness just as can be said of diabetes or hypertension. It is merely a chemical imbalance that can be corrected by chemical magic bullets. This is what we tell our patients, and quite, honestly, we’ve been saying it for so long that we almost believe it ourselves. True, Robert Whitaker, in The Anatomy of an Epidemic, presented substantive, persuasive evidence, based on long-term psychiatric studies, that these medications, though modestly helpful in the short-term, appear to worsen long-term prognosis.  The leaders of our field have roundly dismissed such conclusions as dangerous nonsense, although they have not yet found time to explain why this is so. Nonetheless, these key opinion leaders most assuredly have an astounding depth and breadth of psychopharmacological knowledge. How else could we explain the fact that they are in such high demand for consultations by Big Pharma?  In any case, such oddball concerns about medication efficacy and adverse effects haven’t caused us to modify our practice one whit as you continue to provide generous reimbursement as an incentive to medicate our patients. Presumably, this approach is less expensive than the alternatives.

Revered bureaucrat, as we know, medical practice is determined by who pays for what. We are not so naïve as to believe that the best treatments can always be implemented. We obviously need to focus on what is reimbursable.  In any case, we must remain on guard against rabid skepticism. After all, if we listened to the doubters, we would have to abandon such fine treatments as trepanation and insulin shock therapy. As it turned out, the combination of an antidepressant and an antipsychotic had an undeniable impact. Specifically, she gained 47 pounds and developed diabetes and hypercholesterolemia. Her depression raged on so we bravely added another antidepressant, an additional antipsychotic, an antianxiety medication (clonazepam) and an anticonvulsant (mainly as it was one of the few remaining medications with which we were familiar). Although her speech was slurred and she was a bit disoriented, we did observe that her sleep improved to the point that she had to nap much of the day in addition to a healthy ten hours per night. On the debit side of the ledger, due to impaired balance, she did fall and fracture her hip. Once again, our integrity proved to be our downfall as Ms. Anne Derstoode became noncompliant after our thorough review of potential adverse effects including cerebral atrophy from the second generation antipsychotic medication.

Honorable bureaucrat, we humbly suggest that the time has come to think outside the box. For a moment, let us suspend our belief in the primacy of interventions based on our proven biological theories. In this vein, we propose that we attempt an unconventional, if not radical, approach: spend some time listening to our patient. Please indulge us the opportunity to plead the case for this most atypical treatment. If we were to listen to her and learn more about her problems, we might be able to help her address these. For example, we do know she is now unemployed and homeless. Perhaps she is feeling somewhat isolated and lonely since leaving her abusive husband several months ago and needs to share her story with someone. At this point, there seems to be little to lose in implementing such an unlikely approach.  Although, rarely utilized, there is some evidence that the technique of listening to our patients can be beneficial. For example,  rumor has it that Open Dialogue as implemented in Tornio, Finland  resulted in medication usage in only 20%  and employment rates of 80% of individuals who initially presented with a first episode of schizophrenia;  the inverse of our rates of medication and employment for this patient group. Of course this is not relevant for us as there is no insurance reimbursement for such an approach. We do, however, request permission simply to listen to our patient. Additionally, she may need to consider making some changes in her life. This technique bears some resemblance to the practice of some forms of psychotherapy which mental health clinicians of bygone days sometimes found useful. We recognize the need to be reasonable and to adhere to the community standard of practice so we would not exceed the usual eight allowed visits per annum for this rather bizarre treatment trial. We have not yet asked Ms. Anne Derstoode what she thinks of the idea that we listen to her, but will consider doing so once we receive your reply.

With deepest respect,

Dr. Burnerd Oute

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