James Evans, MD, chief of Emerson’s psychiatry department, is concerned that the stigma of mental illness hangs on and prevents many people from seeking treatment. His current focus is to enhance mental health services in primary care practices, to launch an outpatient Suboxone program, and to expand the use of electro-convulsive therapy, which compares favorably with medication in treating depression.
How has practice changed since your psychiatry training?
In addition to Freudian-style, insight-oriented psychotherapy, we now have cognitive behavioral therapy, which asks the patient to be mindful of what their mind is telling them, and acceptance commitment therapy, which explores personal values and the steps needed to be the kind of person one wants to be. Medications continue to evolve; we expect the FDA to approve Ketamine, an anesthetic agent and “party drug,” for depression, and we have effective procedures, such as transcranial magnetic stimulation, deep-brain stimulation and electroconvulsive therapy.
In terms of substance abuse, there are still many misconceptions in the general public about addiction, but in some ways we have moved to a less punitive approach. This is seen in the Suboxone and Vivitrol programs that are being established, including at Emerson. Finally, the standard of care now is to deliver mental health care in the primary care setting.
How is that proceeding at Emerson?
It’s a challenge. The ideal would be to have psychiatrists embedded in primary care practices, but that is difficult to accomplish because there is a shortage of psychiatrists and due to the ongoing issue of parity. There is simply not the same reimbursement to see patients with mental health problems as is true for other specialties. At Emerson, we have a work in progress with Partners HealthCare to bring social work staff into primary care practices. Partners is also helping with our outpatient Suboxone initiative.
How will the Suboxone program work?
It will be based in the Emerson White House, where our addiction recovery program (ARP) is located. The patient typically is evaluated in the emergency department and may be admitted to North 5 for detox before being transferred to the ARP for intensive outpatient treatment. This work will include the use of Suboxone for patients who are addicted to opiates. We will also use naltrexone and its long-acting version, Vivitrol, in patients with opiate and alcohol addiction. This is now the standard of care: medication therapy and talking therapies, including counseling and groups such as Alcoholics Anonymous. Prescribing Suboxone requires that a physician take an eight-hour course to be certified. We are encouraging physicians to do that, and we will provide backup assistance.
What about the expanded use of ECT?
We know that ECT — electro-convulsive therapy — is effective treatment for major depression, bipolar disorder and catatonia. Among 100 people with depression, 55 will be cured with medication; between 70 and 90 will be cured with ECT. It is safe, including for elderly individuals and pregnant women. Despite explaining to patients that ECT is painless, highly effective and bears little resemblance to what they saw in “One Flew Over the Cuckoo’s Nest,” we still need to spend a lot of time convincing people that this treatment will help them. In the coming months, we will ramp up our ECT program and hope to be able to offer this to outpatients.
Your clinical interests are addiction and geriatric psychiatry.
Yes. I did fellowships at Boston University School of Medicine in addiction psychiatry and geriatric psychiatry. I find both to be rewarding areas. There is something fascinating about how people cope with end-of-life issues — in some cases, successfully and gracefully. Their bodies are failing them, but many people keep a wonderful outlook on life and find that their lives have meaning. It’s true there can be terrible depression, which we can treat. To be involved in that, and to help people at that point in their lives, is rewarding.