Saturday, May 31, 2014

And now for something warm and fuzzy!

Psychiatry these days --- I could do link after link and commentary after commentary about guns and violence and mass shootings and can we prevent all this?  But why?  Let's go for something sweet and warm and fuzzy and ducky today.  I hope you enjoy the video above.

Tuesday, May 27, 2014

Just a Phase?

Today's Shrink Rap post is located over on Clinical Psychiatry News.  "Distinguishing the killers among us" is a story I've written about before here on Shrink Rap, about a situation I dealt with in high school. 

 The timing seemed right to tell the story again. 

Thursday, May 22, 2014

Maryland work group on legislation regarding involuntary care needs PATIENT input!

On May 20th, I attended the Maryland Department of Health and Mental Hygiene (DHMH)'s first Outpatient Services Programs Workgroup, designated by Senate Bill 882/ House Bill 1267.  These were bills proposing legislation to bring outpatient commitment ("assisted" outpatient treatment - AOT) to Maryland and to look at the use of ACT (assertive community treatment) and other outpatient services in Maryland.  The meeting was the first of 8, and they are open to the public.

Since involuntary outpatient treatment is a controversial topic, it's no surprise that the room was full and all the stakeholders were represented.  I'm going to guess there were 120 people there, and I saw people from NAMI, TAC, the public defender's office, the psychiatric society and our diligent lobbyist.  One thing that surprised me was when one man announced that he was one of only three consumers there.  Really?  This is about legislation that might impact people with psychiatric disorders, shouldn't they come to have a say?  I spoke with this gentleman after and was told there was no transportation available to bring people them from their day programs.  But really, aren't there people out there who have been committed to hospitals, who might be concerned about this legislation, who have cars? I guess they'd need to get time off work, as I did.  I also think it's possible they didn't know about the meetings, so I'm posting this here.  I knew about it because I'm on the psychiatric society's legislative committee, and obviously another hundred or so other people knew about it, but if you know someone who might like to attend, please spread the word.  Please be aware that the meetings may be moved to a larger space. 

I hate the idea that stakeholders make these decisions for people -- some of whom are quite outspoken and organized -- without their input.  Those who've benefited from forced care need a voice. And those who've been harmed by forced care also need a voice.  If you have something to say, or you just want to listen to the process, these meetings are open to the public. 

Per Facebook:
DHMH to Convene Behavioral Health Integration Stakeholder Workgroup: Members of the public invited to participate

The workgroup will make recommendations on issues related to behavioral health, including statutory and regulatory changes to... See More

Monday, May 19, 2014

Can Medication Prevent Crime?

Ah, not here, not now, but over on Clinical Psychiatry News, ClinkShrink looks at the question of whether medications can prevent crime and she talks about a study in Sweden that was recently published in Lancet.  Let me redirect you over there:
 Can Medication Reduce Crime?

Sunday, May 18, 2014

The HIgh Cost of Forced Outpatient Care

I'm going to refer you to a long article in The Herald News,  Focus: Safety concerns prompt states to revisit involuntary commitment laws that address the mentally ill.  

Now I'd like to bring you to the end of the article where there is mention of the fact that President Obama has authorized $60 million to fund these programs.  If we divide that evenly between the states, it's about $1.2 million per state.  New York already has a program for involuntary outpatient commitment called Kendra's law.  The studies have shown that it has been successful in decreasing hospitalizations and incarceration.  The costs are calculated  per person "before" and "after" involuntary commitment, so the amount of money shelled out for each patient goes down when they've been put in the program.  What isn't reflected in the cost, is the overhead and infrastructure that New York State put in place to increase services.  I will point out to you that Kendra's law is mostly used in New York City, around Albany, and a few other hot spots, but not in the rest of the state.  And how much money has this successful program cost to implement in these populated parts of New York?  From the website of the NY Office of Mental Health:

Kendra's Law: Final Report on the Status of Assisted Outpatient Treatment
Resources to Provide Court-Ordered Services

The Governor's budget for Fiscal Year 2005-2006 provides more than $32 million for operation of services in support of Kendra's Law. This appropriation continues State support of case management and other services aimed at keeping recipients in a treatment program, including psychiatric medication as required. Since Kendra's Law went into effect, Governor Pataki has also acted to expand access to case management and other key community-based mental health services that would be needed by individuals receiving court-ordered treatment, as well as many other individuals with severe mental illness who have less intensive, but still substantial, service needs. The Governor's budget for Fiscal Year 2005-2006 also provides more than $125 million in ongoing funding for such services. This "Enhanced Community Services" funding has been used to both improve and expand the capacity of the existing community-based mental health system and to strengthen the cohesiveness and coordination of that system. More specifically, Enhanced Community Services were designed to steer the New York State mental health system toward a more person-centered, recovery-oriented service delivery approach, and were targeted for the following purposes:
  • to expand case management, Assertive Community Treatment (ACT), and housing services to support community integration;
  • to develop Single Points of Access (SPOA) to better manage service access and utilization; and
  • to increase the availability of other services that enhance community participation and improve the engagement, quality of life, and satisfaction level of service recipients.
 Many states have involuntary commitment laws. Few of them implement them, as the Herald News article highlights.  It costs too much.  $60 million is not going to do it for a country of 300 million people.  And while we do know that the program reduces hospitalizations and incarcerations in this vulnerable group of very ill, high users of emergency mental health services, what we also know is that the recipients don't like it; satisfaction rates are low (---that statistic doesn't make the news, presumably because no one cares?)

Finally, the article ends by pointing out that involuntary outpatient commitment is not about forcing medications.  This is a common saying of those who support it, but when legislation was proposed in Maryland, the legislation included an order for a specific class of medications and procedures to make changes or contest it.  If a judge tells you that you have to take a medication or you can be brought by the police to a hospital for evaluation, how is this not forced medication? 

Friday, May 09, 2014

Tell Me About Sweden

I've been delving into a recently published study from Sweden that was mentioned here in the Wall Street Journal. The study looked at the effects of psychiatric medication compliance on violent crime. It's interesting and intriguing but I have to say I'm struggling to see how or if this may be applicable to people in the United States. Thus, this blog post. I know from Google analytics that we've had almost 5000 page views from readers in Sweden this month alone. I know that many of our blog readers are patients. Please, tell me about your mental health care system. From the paper I know that your legal system is very different from ours: you essentially have no insanity defense. It appears that the only time mental state issues come into consideration is at sentencing. This means we really can't know how many of those violent crimes actually were due to psychiatric symptoms.

But beyond that fact, I'd like to know how the community response to mental health issues may be different and about differences in the system of care.

Some questions, off the top of my head:
-Are there mobile treatment teams that respond on site to patients in crisis?
-What is the emergency evaluation process, how long does it take, does it work?
-If there is an emergency response, how often do patients get taken to a hospital vs some other alternative?
-What are the involuntary medication laws like? How often is this pursued? How often ordered vs not?
-Are outpatient services integrated with substance abuse treatment and medical care?
-How long does it take to get into outpatient treatment?
-Is there legal enforcement for outpatient treatment? What does it look like? How often is it sought?
-Are there pretrial diversion programs for mentally ill people who get arrested and charged with crimes?
-Any thing else you'd like to tell me?

Don't be limited by my questions. I have trouble believing that a single intervention like medication should have such a significant impact on crime. Disclaimer: this is probably going to be my next Clinical Psychiatry News column, so you may be quoted.

Wednesday, May 07, 2014

Privacy versus Necessary Communications

Greetings from New York.  All the Shrink Rappers have been enjoying the APA meetings these past few days.  

Today's post is located over on the Clinical Psychiatry News website: Legislation's privacy exceptions of psychiatric patients are concerning.  Do surf over and read the post there