56 MAY 2015PSYCHIATRIC TIMES www.psychiatr ic t imes.com

from my lips. I struggled to maintain composure during that sad period of my life. Often engulfed by tension, I used the following “system of com-fort” to reduce the stress:

Whenever I found my shoulders tightening or my legs aching, I did relaxation exercises, and I talked to myself out loud about accepting the worst and moving on. When I thought of going to jail, I countered with, “The worst is that I will go to jail. Well, Gandhi went to jail. If I have to, so be it. Murderers start a new life after incarceration. I will do that too.” I did not realize that I hadn’t broken any laws, and there was no chance that I could go to jail.

When I thought about losing my medical license, I told myself, “There are many people who are not doctors. They live full lives. I will open a 7-Eleven store.” My mantra became, “I will cross the bridge when I see the bridge.”

Whenever I felt that I was project-ing my anger onto my patients, I would say, “I am generalizing. It is unfair to the innocent others.” I re-peated my concept of the serenity prayer so that I could focus on things that were in my control: “May I have the serenity to accept that I have no control over the outcome of the suit. Let me have courage to continue my practice, serve my patients, earn money, and prepare for the suit. Let me have wisdom that the lawsuit is not in my control, but my ability to fight is under my control.”

The trialThe 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 what the time is. Your response should be ‘Yes, I have the time.’ If I ask, ‘What is the time?’ You should say, ‘2 pm.’ Do not give more infor-mation than what he [the opposing attorney] asks. You may be giving self-incriminating answers. I will be listening. If there is a fact that you need to clarify, I will ask later.”

Jury selection was completed, and the trial began in mid-2009. The plaintiffs had a lawyer, and the hospi-tal and I (the defendants) had sepa-rate lawyers. A couple of days were spent going over the case with the judge to come up with an opening statement. The three lawyers agreed on the following statement: “Mr Ku-lik jumped out of the window and died.” The lawsuit would decide

whether the hospital and the doctor did their jobs.

Engineers gave testimony about the window—its quality and manu-facture. The patient’s sons and wife, the internist, the nursing director, and the nurse in charge gave tes-timony. The latter had visited Mr Kulik every hour that night up to 40 minutes before he was discovered missing. They all said that Mr Kulik had been improving, and there were no talk or behavioral changes to alert anyone of a problem. When it was my turn to take the stand, I was deter-mined to remain consistent in my testimony. During the testimony:• I kept a pleasant disposition in spite

of my inner anxiety.• I answered in lay language: I used

my knowledge about bipolar disor-der, suicidality, and interviewing, and I made sure that what I said did not conflict with the hospital chart, form C (3), and my deposition.

• I looked straight into the eyes of the lawyers, except when I was asked to explain to the jury; I then made direct eye contact with the jury members.

• The plaintiff’s attorney asked, “Why didn’t you ask Mr Kulik about suicide?” I explained and en-acted the inappropriate affect, talk, and facial expressions of Mr Kulik. Thus, I showed the jury that Mr Kulik was not capable of giving re-liable answers to my questions.

• I recorded the duration of my con-sult and follow-up visit on the hos-pital records. It was my practice for billing purposes and for Medicare audit. That habit proved to be a

blessing. On the first day, I spent 55 minutes with the patient and on the second day, 25 minutes. The plain-tiff’s attorney could not harass me about my short notes when he saw those numbers.

• My attorney confirmed that the statement “My father likes you; I will like to bring him to you after discharge from the hospital,” was made by the patient’s son during his testimony.

The jury deliberated. I was unsure whose side made more sense to the jury and worried about their deci-sion. Finally the verdict came in: the hospital was found negligent be-cause a nurse had seen a faulty win-dow but did not report it and get it repaired in time. I was found not guilty of negligence.

I left the building. I wanted to cel-ebrate by shouting with joy; how ever, I kept the dignity of a doctor. The family was standing outside in the parking lot. They saw me coming, the son approached me, and he said, “You are a good doctor, but we had to do this. He was our father you know.”

I wanted to yell at them and curse them for wasting 4 years of my life. I thought that they did not have to apologize, but they did. It was my turn to be gracious. I said, “I under-stand, but it was very hard on me.” All of them smiled wishing me good-bye. I moved on.

Eight days later, I received a letter. “Ordered that a judgment be and is hereby entered in favor of the defen-dant, Harish Malhotra, MD, and the complaint be and is hereby dismissed with prejudice and without costs.”

The dismissal was “with prejudice,” which was significant. It meant that the matter can never be reinstated against me anytime in the future, for any reason.

The following are some lessons I learned from this suit:• The service you have provided is the

one that you document; if it is not documented, you did not perform it. Always record the amount of time you spent with the patient.

• Make it a habit to question all pa-tients about suicidality, violence, and adverse effects—and document that you did; if they are present, document a rational reason for your decisions, actions, or inactions.

• In your record, use the word “be-cause” frequently; it conveys that you are reflective and rational.

• Dictate records and work hard to improve your handwriting—it is embarrassing when you cannot read your own writing.

• Be sure that all collateral informa-tion and its sources are included in the record.

• A lawyer is your best friend during a lawsuit—you are very lucky if you get a good one.

• Please read about malpractice to learn precautions that you need to take and ways to deal with a mal-practice suit.

Dr Malhotra is Clinical Associate Professor at Rutgers New Jersey Medical School in Newark. He reports no conflicts of interest concerning the subject matter of this article.

Acknowledgment—I am thankful to the US judicial process for its fairness. ❒

PSYCHIATRIC MALPRACTICEDefending a Malpractice SuitContinued from page 55

COMMENTARY

Correcting Psychiatry’s False Assumptions and Implementing Parity

by Eric M. Plakun, MD

I t is a source of shame for our na-tion that for most Americans in need—especially those with se-

rious mental illness—the mental health system is dysfunctional. Pro-vision of population mental health services is a complex systems issue that requires multiple stakeholders to work in partnership to improve it. Federal and state governments

(as funders of both care and re-search), clinicians, hospitals, ac-countable care organizations, and insurers, as well as patients and families, are key stakeholders. Only the federal government has author-ity to convene all of the former, but Washington’s current dysfunction makes this unlikely. Nevertheless, we can fix some of the ways the sys-tem is broken. I will focus here on 2 critical areas—the paradigm of

clinical care and implementation of parity.

Psychiatry’s false assumptionsPsychiatry clings to 3 false assump-tions despite evidence to the con-trary, and psychiatrists, our patients and their families, and our nation pay a price as a result. The assump-tions are that:• Genes = disease

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www.psychu.org

COMMENTARY• Patients present with single dis­

orders that respond to single evi­dence­based treatments

• The best treatments are pills

Genes = diseaseMental disorders are clearly herita­ble. Molecular genetic research teaches us that there are 2 kinds of genes—those that make proteins and those that regulate other genes, often in response to the environ­ment. We hoped that sequencing the human genome would lead to identification of the genetic under­pinnings of mental disorders, but genes turn out to be rough plans rather than detailed blueprints for an individual.

Over 125 relevant genetic loci have been identified in schizophre­nia, which indicates that heritabil­ ity of this and other psychotic dis­orders is far more complex and mul­tifactorial than we expected. Single nucleotide polymorphisms (SNPs) are associated with some cancers, type 2 diabetes mellitus, and inflam­matory bowel disease. Genome­wide association studies of depres­sion were unable to find meaningful SNPs that illuminate genetic un­derpinnings of this common disor­der.1 No biomarkers for depression

have been found, and the search for them has been likened to that for the Holy Grail.

Meanwhile, Tully and colleagues2 offer us a glimpse of the importance of environmental factors in depres­sion by demonstrating that mothers who are depressed during childrear­ing often have depressed adoles­cents—whether their children share their genes or are adopted. Other studies of early adversity demon­strate that it is a veritable “enviro­marker,” associated with a high risk of mental illness, substance use, and medical disorders—not just with PTSD.3

Emerging evidence shows us that disease is not simply encoded in genes, but that gene­by­environment interactions (“epigenetics”) are cen­tral in understanding disorders. Yet as a profession, psychiatry has shift­ed toward what former APA presi­dent Steve Sharfstein called in his presidential address the “bio­bio­bio” model. Many in psychiatry have moved away from and some­times deride the biopsychosocial model. Ironically, this has happened as the above evidence from genetics has cautioned us to take environ­mental factors more seriously. Nu­merous studies demonstrate the ef­

fectiveness of psychodynamic psy­ chotherapy and CBT for multiple individual and complex comorbid disorders—with the ability to distin­guish therapy responders from non­ responders on imaging.4

The assumption that disease is all about genes and biology does help reduce blame and stigma. Neverthe­less, the assumption doesn’t fit the evolving data, and clinging to it risks crippling our ability to understand and treat our patients’ problems in nuanced and sophisticated ways that attend to biological and environ­mental factors in a “both/and” rather than “either/or” model. After all, an­other way to say “epigenetics” or “gene­by­environment interactions” is “biopsychosocial.”

Patients present with single disorders that respond to single evidence-based treatmentsOur practice guidelines and our ran­domized trials assume that most pa­tients have single disorders that re­spond to evidence­based treatments in carefully selected non­comorbid patient samples. Yet, clinicians know from practice­based evidence what the research evidence shows: most patients have multiple comorbid dis­

orders and failure rates for our best treatments are high.

For example, in depression, 78% of patients in the large STAR*D sam ple presented with comorbidity or suicidal ideation that would have excluded them from randomized tri­als; however, these comorbid pa­tients had lower response to treat­ment and lower remission rates.5 So if you feel, as many clinicians do, that the patients you work with are sicker than those a drug was tested on, you are right about 4 times out of 5.

Again using depression as an ex­ample, we are learning how impor­tant comorbid personality disorders are to treatment outcome—espe­cially comorbid borderline person­ality disorder (BPD). The large, multisite Collaborative Longitudinal Personality Disorders Study (CLPS) concluded that the presence of per­sonality disorders, especially BPD, “robustly predicted persistence” of MDD, suggesting diagnosis and treatment of personality disorders are essential in treating depression lest it become treatment­resistant.6

However, in our focus on the medical model, personality disor­

(Please see Implementing Parity, page 58)

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orders should be treated either as inpatients or outpatients, with no ac-cess to intermediate levels of care (such as residential treatment), seems inconsistent with parity legis-lation. Would a man with a stroke be told that once he was no longer in need of acute inpatient treatment, he had to return to outpatient treatment, with no access to intermediate levels of care to begin to learn to speak, walk, and resume self-care?

Despite parity legislation, many insurance companies continue to deny access to care based on such arbitrary exclusions. Successful le-gal challenges can establish case law fully implementing mental health parity. The good news is that such

lawsuits, some as class ac-tions, are under way and are gaining traction.

In December 2014, the CBS show 60 Minutes de-voted part of an episode to a lawsuit (Wit et al v United Behavioral Health) about ar-bitrary denial of residential treatment to patients with complex comorbid mood, eating, and substance use disorders. The segment made clear the devastating con-sequences to seriously ill patients of a pattern of re-flexive denial of care by managed care reviewers. In another class action suit

(Craft et al v Health Care Service Corporation) in March 2015, the judge ruled against the insurance company’s motion to dismiss, which claimed the lawsuit lacked merit because the insurance con-tract specifically excluded residen-tial care. The ruling is promising to the plaintiffs because it suggests the judge sees exclusion of residential treatment as a non-quantitative lim-it prohibited by parity. Other cases hold managed care or ganizations accountable for other quantitative and non-quantitative limits on care. Their outcomes have the potential to force reform of egregious man-aged care practices that are part of what is broken in our mental health system.

Together our voices matter. Please consider joining “Biopsycho-social Matters,” for discussion of is-sues such as these at www.meaning matterscommunity.org.

Dr Plakun is Associate Medical Director of and Director of Admissions at the Austen Riggs Center in Stockbridge, Mass. He was a Harvard Medical School clinical faculty member for over 20 years. Editor of two

ders are underdiagnosed. In DSM-IV, the most frequent Axis II di-agnosis made was “deferred,” and there is no reason to think this will change with DSM-5. Biological tun-nel vision can lead to missing the reality of clinical complexity and interfere with provision of optimal patient care.

The best treatments are pillsWe have overestimated the efficacy of antidepressants by about a third when all studies are considered, and 75% of antidepressant effect is pla-cebo effect.7,8 The CATIE schizophrenia study showed that patients don’t find that the benefits of our pills out-weigh the adverse effects.9 Our pills work, but not as well as we might hope, while the effect sizes of psycho-therapy studies are actually larger than those for medica-tions.10 In some disorders, the combination of psychother-apy and medications is su-perior to medications alone, and when early adversity in-cludes sexual abuse, medica-tions may add little to the outcomes achieved with psy-chotherapy alone.11

Psychiatry has reified skills in di-agnosis and prescribing medications as defining characteristics. If we take seriously the message that genes and environment matter in the causation and treatment of disor-ders, we will need to focus much more on training in and the practice of psychosocial treatment in psy-chiatry—or surrender our role as the most sophisticated mental health cli-nicians. You can’t practice what you aren’t taught—and can’t teach what you never learned. However, cur-rently the only place within the APA that stands for the importance of psychosocial factors in the causation and treatment of mental disorders is the unfunded APA Psychotherapy Caucus. The Caucus originated in 2014 as a grassroots effort by a doz-en APA members concerned that the APA leadership saw no reason to es-tablish or fund such a group within its Components. The Caucus has grown from 12 founding members in early 2014 to over 200. All inter-ested psychiatrists are invited to join by contacting me at Eric.Plakun@ austenriggs.net.

Psychiatry would be well advised to rethink its identity and to reaffirm the biopsychosocial paradigm to im-

prove patient care. Attending to the importance of psychosocial or envi-ronmental factors also means taking more seriously the contributions of psychoanalytic theory, which has studied environmental influences for over a hundred years and, as Nobel laureate neurobiologist Eric Kandel12 stated, offers the most nu-anced and sophisticated model of the mind that we have.

Psychodynamic psychiatry, which is the intersection between general psychiatry and psychoana-lytic theory, deserves renewed atten-tion as part of fixing a broken sys-tem. This does not mean offering individual psychoanalysis to more patients, but it does mean including

Implementing ParityContinued from page 57

COMMENTARY

psychoanalytic perspectives in our work with patients. This can occur through the practice of “psychody-namic psychopharmacology” that attends to the meaning effects as well as the neurochemical effects of medications, through knowledge of individual and group dynamics and defense mechanisms to help psychi- atrists be better therapists and better treatment team leaders, and through faithful attention to the authority, agency, and competent voice of the patient in negotiating an alliance and in treatment.13

Psychoanalysis is not the only psychosocial treatment worth our attention. CBT, DBT, and other be-havioral therapies, as well as group and family therapy, have much to offer. Attention to common factors shared by evidence-based behav-ioral and psychodynamic therapies offers hope of training those psychi-atrists who will never master a man-ualized therapy to better treat diffi-cult patients, such as suicidal pa- tients with BPD.14,15

There are more issues that must remain unaddressed here, such as future directions in diagnosis and why the NIMH spends the vast bulk of its research dollars studying

brain function rather than common factors across psychosocial treat-ments that could directly improve patient outcomes.

Full implementation of parityMental health care is approved and funded in a managed care model. Managed care operates with the same moral imperative as the envi-ronmental movement—focused on preserving limited resources. But US managed care companies usu-ally function as revenue-driven de-niers of care, especially in mental health. A recent study published in JAMA Psychiatry revealed that only 55% of psychiatrists accepted in-surance in 2009-2010 compared

with 88.7% of physicians in other medical specialties.16 The data fur-ther revealed significantly lower Medicare and Medicaid acceptance rates among psychiatrists than phy-sicians in other medical specialties. Low rates of reimbursement for mental health services; quantitative limits, such as annual limits on numbers of sessions or dollars avail-able for care; and non-quantitative limits, such as utilization review hurdles for prior authorization ac-count for much “opting out” of the system of care.

Though understandable given the context, these high “opt out” rates are a national embarrassment. The Mental Health Parity and Addiction Equity Act (MHPAEA, or parity law) offers hope of a remedy, since it forbids quantitative or non-quantita-tive mental health care limits more restrictive than those in medical and surgical care. For persons with dia-betes mellitus, arbitrary annual lim-its in the number of office visits or dollar limits for services would be unthinkable, but such limits are of-ten imposed for people with mental disorders.

Similarly, the managed care stance that patients with mental dis- (Please see Implementing Parity, page 60)

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CLINICAL

tive attributional style and lower self-esteem. We have found that because of the often challenging nature of diagnosing depression in individuals with ID, clinicians frequently find themselves relying on the biological symptoms of depression for diagno-sis: sleep and appetite disturbance, poor concentration and memory. Mayville and colleagues6 found that persons with depression and ID had a lower food intake than those with ID who were not depressed.

A review of rapid cycling bipolar affective disorder found that hyper-somnia occurred in 70% of sleep-disturbed depressed patients with ID.7 There is little literature on the presentation of mania in individuals with ID. In their review of rapid cy-cling bipolar affective disorder in persons with ID, Vanstraelen and Tyrer7 found that mood states were generally described in terms of ob-servable behavior rather than affec-tive state. They found that signs of manic episodes typically included insomnia, increased activity, pres-sured speech, and agitation.

Because of the lack of random-ized controlled trials for the man-agement of anxiety, depression, and bipolar affective disorder in persons with ID, recommended pharmaco-logical options do not differ signifi-cantly from those for individuals with intelligence in the normal range. It is worth emphasizing that efforts should be made to identify and manage potential precipitating and perpetuating factors (eg, change in environment, disrupted sleep).

dividuals with ID can experience communication difficulties that vary from problems expressing psycho-logical experiences to being unable to produce speech. As may be ex-pected, this results in an under- reporting of psychiatric symptoms.3 Clinicians must be aware of this and place great er emphasis on observ-ing the individual and on obtaining collateral history from family and care staff.

There can be a tendency to attri-bute any behavioral/psychological disturbance to an individual’s ID (known as diagnostic overshadow-ing).4 This significantly increases the risk of missed diagnoses. Individuals with ID often have the same form of psychopathology (eg, auditory hal-lucinations) as those with intelli-gence in the normal range. However,

© ABSTRACT/SHUTTERSTOCK.COM

Intellectual Disability and Psychiatric Comorbidity: Challenges and Clinical Issues

by Kimberley Kendall, MBBCh and Michael J. Owen, PhD, FRCPsych

I ntellectual disability (ID) is the impairment of general mental abil ities, which affects an individ-

ual’s functioning in everyday life. According to DSM-5, ID has an im-pact on 3 broad domains in a per-son’s life: conceptual (eg, language and memory), social (eg, empathy, social judgment), and prac tical (eg, personal care, money management).1 Individuals with ID have a higher risk of psychiatric disorders than in-dividuals with intelligence in the normal range: prevalence is as high as 40.9% based on clinical diagnosis and 15.7% based on DSM-IV-TR.2 When specific ID diagnostic criteria are used (diagnostic criteria for psy-chiatric disorders for use with adults with learning disabilities [DC-LD]), the most common comorbid psychi-atric disorders are problem behavior (18.7%), affective disorder (5.7%), autism spectrum disorder (4.4%), psychotic disorder (3.8%), and anxi-ety disorder (3.1%).2

Problem/challenging behavior is heterogeneous and its assessment and management are beyond the scope of this article. The focus here is on the comorbid presentation of affective and anxiety disorders, psy-chotic disorder, and autism spectrum disorder.

ChallengesSpecific challenges in the field of ID can make the diagnosis of comorbid psychiatric disorders difficult. In-

the content of this psychopathology can differ significantly (see Case Vignettes for examples). As a result, the presentation of a comorbid psy-chiatric disorder in this group is of-ten atypical. Be alert to this when conducting assessments.

Affective and anxiety disordersAffective and anxiety disorders occur in individuals with ID at a rate of around 5.7% and 3.1% respectively.2 In addition to the classic symptoms seen with these disorders, their atypi-cal presentation can include features such as aggression and self-injurious behavior.

In a study on depression symp-toms in individuals with ID, Es-bensen and Benson5 found that those with MDD and ID had a more nega-

books, including Treatment Resistance and Patient Authority: The Austen Riggs Reader (WW Norton & Company, 2011), and author of over 40 published papers and book chapters, he has presented widely in the US and over­seas. Dr Plakun is a Distinguished Life Fellow of the American Psychiatric Association, Past Chair of its Committee on Psychotherapy by Psy chiatrists, and founding leader of its Psycho therapy Caucus. He is a past member of the APA Assembly Executive Committee, and Past Chair of the Assembly Task Force on Psychotherapy by Psychiatrists. Dr Plakun is a Psychoanalytic Fellow of the American Academy of Psychoanalysis and Dynamic Psychiatry and a Fellow of the American

College of Psychoanalysts and the American College of Psychiatrists. He has been hon­ored as the Outstanding Psychiatrist in Clin­ical Psychiatry by the Massachusetts Psy­chiatric Society.

References

1. Hek K, Demirkan A, Lahti J, et al. A genome-wide association study of depressive symptoms. Biol Psy­chiatry. 2013;73:667-678.2. Tully EC, Iacono WG, McGue M. An adoption study of parental depression as an environmental liability for adolescent depression and childhood disruptive disorders. Am J Psychiatry. 2008;165:1148-1154.3. Molnar BE, Buka SL, Kessler RC. Child sexual abuse and subsequent psychopathology: results from the National Comorbidity Survey. Am J Public Health. 2001;91:753-760.4. Lazar SG. Psychotherapy Is Worth It: A Compre­hensive Review of Its Cost­Effectiveness. Washing-ton, DC: American Psychiatric Publishing, Inc, 2010.5. Wisniewski SR, Rush AJ, Nierenberg AA, et al. Can phase III trial results of antidepressant medications

be generalized to clinical practice? A STAR*D report. Am J Psychiatry. 2009;166:599-607.6. Skodol AE, Grilo CM, Keyes KM, et al. Relationship of personality disorders to the course of major de-pressive disorder in a nationally representative sample. Am J Psychiatry. 2011;168:257-264.7. Turner EH, Matthews AM, Linardatos E, et al. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med. 2008;358:252-260.8. Kirsch I, Deacon BJ, Huedo-Medina TB, et al. Initial severity and antidepressant benefits: a meta-analy-sis of data submitted to the Food and Drug Adminis-tration. PLoS Med. 2008;5:e45.9. Lieberman JA, Stroup TS, McEvoy JP, et al; Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Investigators. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia [published correction appears in N Engl J Med. 2010;363:1092-1093]. N Engl J Med. 2005;353: 1209-1223.10. Shedler J. The efficacy of psychodynamic psy-chotherapy. Am Psychol. 2010;65:98-109.11. Nemeroff CB, Heim CM, Thase ME, et al. Differ-ential responses to psychotherapy versus pharma-cotherapy in patients with chronic forms of major

depression and childhood trauma [published cor-rection appears in Proc Natl Acad Sci U S A. 2005; 102:16530]. Proc Natl Acad Sci U S A. 2003;100: 14293-14296.12. Kandel E. Paper presented at: Meeting of the American Psychoanalytic Association; January 2011; New York.13. Plakun EM, ed. Treatment Resistance and Patient Authority: The Austen Riggs Reader. New York: WW Norton & Company; 2011.14. Laska KM, Gurman AS, Wampold BE. Expanding the lens of evidence-based practice in psychother-apy: a common factors perspective. Psychotherapy (Chic). 2014;51:467-481.15. Sledge W, Plakun EM, Bauer S, et al; Group for the Advancement of Psychiatry Psychotherapy Com-mittee. Psychotherapy for suicidal patients with bor-derline personality disorder: an expert consensus review of common factors across five therapies. Borderline Personality Disorder and Emotion Dys-regulation. 2014;1:16. http://www.bpded.com/ content/1/1/16. Accessed April 16, 2015.16. Bishop TF, Press MJ, Keyhani S, Pincus HA. Acceptance of insurance by psychiatrists and the implications for access to mental health care. JAMA Psychiatry. 2014;71:176-181. ❒

Implementing ParityContinued from page 58

COMMENTARY

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