Tuesday, October 27, 2015

More of What I learned at the MGH Psychopharm Course

 I'm back in Maryland, but I am still thinking about all that I learned at the MGH course.  Let me see what else I can add of interest.  Let me put in a plug for the course: It was an excellent catch-up class on practical aspects of psychopharm.  Highly recommended, and I'll go again in a couple of years.

Dr. Bianchi on sleep disorders, mainly insomnia
~Medicines of all types change sleep architecture and reduce REM sleep. There's no evidence that these changes have meaningful clinical correlates.
~Melatonin -- start at 0.5mg and go up, take 3 hours before sleep, and it's contraindicated for patients on coumadin.
~People's perceptions of their sleep is not accurate.  Ambien increases total sleep time by 40 minutes; people estimate they've slept two hours longer.
~Trazodone doesn't work. (I'm just the messenger here)
~Suvorexant (Belsomra) -- the first orexin antagonist.  There were safety concerns at the higher dose and efficacy concerns at the lower dose which was FDA approved.
~You can try herbals and lavendar drops on your pillowcase
~20-50% of insomniacs have sleep apnea. Even if they are skinny and don't snore.  Who knew?
~CBT! Try an online course, but if you need to know, there are 8 clinics in Boston that offer CBT specifically for insomnia.

Dr. Freudenreich on First-Episode Psychosis 
~The average time from onset of psychotic symptoms to starting treatment is 74 weeks
~In one study, giving patients with a psychotic prodrome 12 weeks of fish oil dramatically decreased the number who went on to be diagnosed with schizophrenia.  
~Adding metformin to the regimen may improve metabolic parameters
~New stuff: Brexipiparzole (Rexulti) and Invega Trinza (a long acting injectible that can be given once every 3 months).
~Best antipsychotic is still Clozapine.

~While medications prevent relapse of psychotic symptoms, they are not comprehensive treatment for schizophrenia.

More later.


Monday, October 26, 2015

I'm sorry, now which box did you want me to write my NPI number in?

I'm soliciting wisdom from our readers on how to fill out a HCFA claim form.  I'll start by telling you that my NPI number on the submitted form was in block 33A.  My legacy number was not on the form.  This is the third such notice I've gotten, and clearly, I'm doing something wrong.  Perhaps you can help?

Saturday, October 24, 2015

What I'm Learning at the MGH Psychopharm Conference, Continued

Moving right alone here, but I'm now many lectures behind.  I'll do my best:

Dr. Jenike on Obsessive Compulsive Disorder
"It's almost unheard of to have a patient get all better."
~SSRI's are the usual medication, often at higher doses than used to treat depression.
~Cognitive Behavioral therapy is the best augmenter.
~MAOIs may help with OCD with panic attacks.
~Lots of other stuff has been tried including Dilantin, Neurontin, morphine, Zofran, pindolol, tramadol St. John's Wort, inositol.
~Glutamate may be involved in OCD and medications that effect glutamate have shown some promise, Including Namenda (memantine), riluzole (a medicine used to treat ALS), and N-Acetylcysteine
~In sudden onset of OCD, consider infectious etiologies, including PANDAS (Google it)

Dr. Simon on PTSD
~propranolol doesn't seem to prevent PTSD (sorry, Roy)
~People who get opiates may be less traumatized -- better pain control likely
~steroids may have some some role in preventing PTSD if administered soon after a trauma
~Don't use benzos for PTSD, they interfere with extinction learning and ultimately make PTSD worse.
~Don't use benzos for PTSD.
~Prazosin helps with nightmares. Lunesta may help with insomnia
~SSRIs help, but not a lot.  Risperidone and quietiapine may be helpful, there is not enough data to say much about other antipsychotics.
~There's not enough data to support that smoking marijuana is helpful.
~We need more research.

Dr. Zakhary on OCD-related disorders: Body dysmorphic disorder, trichotillomania (hair pulling), skin picking and hoarding
~There are no FDA approved medications to treat these disorders.  Check out http://Trich.org
~People with body dysmorphic disorder can spend up to 8 hours/day looking in the mirror.
~SSRIs may help.  There is no indication for using an antipsychotic even if the patient is delusional.
~Tricotillophagia is the name for eating the hair after it's been pulled out.  You learn something new every day.
~N-acetylcysteine may be helpful (NAC), dose of 1200mg -2400mg/day.  Brand names Jarrow or Swanson, and you can get it from Amazon.  Swanson is cheaper.
~Also Naltrexone at 50-100mg, or Olanzapine, 10mg/d
~For skin picking: SSRIs may help.  Olanzapine 5mg/d, Abilify 5-10mg/d, Lithium, or Milk Thistle. It's all case reports.
~An itch workup should be done.
~Hoarding: medications studies are inconsistent and very limited.  CBT!

So, I've gotten you to 5:15 yesterday.  I went to sessions on Sleep Disorders (avoid meds, refer for >CBT!, and apparently trazadone doesn't work) and Natural medications for psychiatric disorders at night, and then dinner at a wonderful French restaurant on Newbury Street with a friend.  It made for a late night, and it all started over this morning with more to come tonight, and all day tomorrow.

Thanks for listening.

Friday, October 23, 2015

What I'm Learning at the MGH Pscyhopharm Conference (Part 0.5)

Greetings from Boston!

I am here, with 750 or so psychiatrists, at the Massachusetts General Hospital's 39th annual psychopharmacology conference.   I wanted to update my medication knowledge, and the meeting runs through the weekend.  The day has been stuffed with useful information, and really good lectures -- much too much to blog about and there are still 2 hours left tonight.  Let me just give you a sample from each lecture:

Dr. Nierenberg on Bipolar Depression:
He suggested checking out MoodNetwork.org
"Bipolar depression is really hard to treat; so many people don't get all the way better."
~People can be depressed, manic, anxious and irritable all at the same time.
~Antipsychotics and a  mood stabilizer aren't much better than antipsychotics alone.
~There are 4 FDA approved treatments for bipolar depression: olanzapine/fluoxetine combo, quietipine (Seroquel), Lurasidone (Latuda), and Lamotrigine (Lamictal)
~Seroquel's response rate is the same for 300mg as for 600mg
~Latuda's response rate is the same for 20-60mg as for 80-120mg
~Lamotrigine is not approved for the acute treatment of bipolar depression, but for prevention.  It is well tolerated.
~Lithium + Lamictal are more effective to prevent depression than mania.
~Some people use antidepressants alway, some never : the experts can't agree.
~Low dose Abilify has been disappointing in bipolar depression.
~Single dosing at night may prevent renal complications.

Dr. Perlis on Long-term management of Bipolar Disorder
You only know if someone has bipolar depression after they've had an episode of mania; family history or early age of onset don't make the diagnosis if the patient is depressed.
~Effective antimanic agents: lithium, valproate, carbamazepine, any antipsychotic.
~Lamictal, gabapentin, and toprimate have not been shown to be effective for mania
~Lithium decreases the risk of suicide.
~Aim for a level of at least 0.6, but risk of renal damage increases with time (decades) and levels (>0.8)
~Lithium and valproate are better than valproate alone
~This guy likes lithium.

Dr. Fava on Treatment-resistant depression
Strategies: increase dose, change medications, augment, combine.
~Buspirone is a safe agent to use for augmentation
~Mirapex (pramippexole) --can go gradually up to 1.5mg bid
~There is some way to get a compounding pharmacy to make intranasal ketamine, but this needs to be monitored.
~Lots of stuff has been tried.

More later --  

Wednesday, October 21, 2015

News Flash: Psychotherapy is Helpful in Schizophrenia

In yesterday's New York Times, there was an article by Benedict Carey titled New Approach Advised to Treat Schizophrenia.  Carey writes:
Now, results of a landmark government-funded study call that approach into question. The findings, from by far the most rigorous trial to date conducted in the United States, concluded that schizophrenia patients who received smaller doses of antipsychotic medication and a bigger emphasis on one-on-one talk therapy and family support made greater strides in recovery over the first two years of treatment than patients who got the usual drug-focused care.
And I thought: This is news?  Obviously, anti-psychotics have side effects, adverse effects and risks, so using using the lowest effective dose is good.  If it takes a high dose of medication to quickly control an acute episode, it's often possible to back down on the dose after the condition has been stabilized.  Talk therapy is often helpful, and of course family support makes all the difference in the world to anyone with a chronic illness or disability.

I was relieved to see that Peter Kramer's tweet:

Oct 20
Psychotherapy helps in schizophrenia = what psychiatrists in my cohort have always believed, as a guide for practice
So I wasn't imagining that this "news" was obvious.  

Later, Dr. Mark Komrad wrote in to our psychiatric society listserv:

"Everyone is talking about this big finding reported in today's NYTs. I'm not sure what's new here. Isn't this how we have been treating schizophrenia all along?  At least everyone I know who treats schizophrenia uses all of these techniques--both in private offices and clinics. What am I missing?  Maybe the lower doses of meds--but don't we all try to use the lowest doses possible?"  

If you'd like to look at the original article, the link is Here
The study by Kane, et.al is notable for the following:
There were 404 individuals enrolled in 34 community mental health centers in 21 states.

"The experimental treatment, NAVIGATE (19), includes four core interventions: personalized medication management (assisted by COMPASS, a secure, web-based decision support system developed for RAISE-ETP); family psychoeducation; resilience-focused individual therapy; and supported employment and education (SEE)."

In case you're interested, in Maryland, the wait-time to get into the agency that does supported employment is 16 months and there are currently 2,586 people on the wait list.  That's not related to the study, but I just thought you might like to know.   Getting back to the study now:

"The control condition, “community care,” is psychosis treatment determined by clinician choice and service availability."

Assessment of the outcomes was made in the following way: "Trained interviewers using live, two-way video conferencing performed diagnostic interviews and assessments of symptoms and quality of life."

Select Results -- I've copied and pasted them, picked out only the ones I thought might be relevant to our readers, and taken out some of the statistics: 

  • Participants assigned to NAVIGATE remained in treatment longer than community care patients (a median of 23 months compared with a median of 17 months, and were more likely to have received mental health outpatient services each month than community care subjects (a mean of 4.53 services, compared with a mean of 3.67 services);
  • NAVIGATE participants experienced significantly greater improvement during the 2-year assessment period than those in community care ; . 
  • More improvement was also found on the subscales “interpersonal relations,” “intrapsychic foundations” (i.e., sense of purpose, motivation, curiosity, and emotional engagement), and engagement with “common objects and activities.” Service Use and Resource Form data showed significantly greater gains for NAVIGATE regarding the proportion of participants who were either working or going to school at any time during each month. 
  • The average rate of hospitalization was 3.2% per month for NAVIGATE participants and 3.7% per month for community care participants. Over the 2 years, 34% of the NAVIGATE group and 37% of the community care group (adjusted for length of exposure) had been hospitalized for psychiatric indications (n.s.). 
  • Finally: Median duration of untreated psychosis was a significant moderator of the treatment effect on total Quality of Life Scale and PANSS scores over time . There was a substantial difference in effect sizes comparing the change between treatments for participants with a duration of untreated psychosis of ≤74 weeks and those with a duration of untreated psychosis of >74 weeks.

No where in the article does it say how medication doses differed in the two groups.  And while the NYTimes piece has been interpreted to say that psychotherapy is helpful in schizophrenia, the study adds a number of different interventions, a specific type of one-on-one psychotherapy being only one. Perhaps the bigger issue  rests with this statement in the researchers' conclusions, that long periods of untreated psychosis are hare more difficult to treat.
The observation that patients with shorter duration of untreated psychosis derived substantially more benefit from NAVIGATE is important. Prolonged duration of untreated psychosis is an issue of national importance; reducing duration of untreated psychosis from current level of greater than 1 year to the recommended standard of  less than 3 months should be a major focus of applied research efforts.

In sum: Patients with schizophrenia do better if they get comprehensive services, and they do better if they are treated early in the course of their illness.  And now we officially know what we all knew.

Saturday, October 17, 2015

Box 21

  I received an email from the APA the other day noting the following:

APA learned today that Medicare providers who file 1500 Health Insurance Claim Forms are having a large number of their claims returned due to a change in the reporting requirements that went into effect on October 1, 2015.

Medicare contractors are returning claims for correction or resubmission to mental health professionals who fail to indicate in line item 21 of the 1500 claim form whether ICD-9 or ICD-10 codes are used.
For services that were provided prior to October 1, 2015, ICD-9 codes should be used even if the claim is filed after that date; for services on or after October 1, 2015, ICD-10 codes should be used. ICD-9 codes are indicated by using a 9 in item #21; ICD-10 codes are noted with a 0.
Really?  The codes look totally different, Medicare can't figure out if the codes are DSM-IV-TR codes or ICD-10 codes?  Especially since it might be safe to assume that codes filed after October 1st are ICD-1O codes if they look like ICD-10 codes?  I generate the forms with a computer program, and I went to add the "0" to the template so it would automatically populate every form, but the program doesn't even have a box 21.  
As you may know, from the roughly 26 Medicare posts I've written,  I often feel jerked around by Medicare. In the past couple of weeks I got a form back saying that it was being rejected because I had my name,address, and NPI number in both box 32 and 33.  It does ask for it twice and I've supplied it this way for years.  I took it out of some of the forms, but not everyone's. Then I got a form back because my address was not in box 32 (I guess they couldn't get the information from box 33, millimeters away).  I added my address to box 32 and resubmitted the form.  I then got the same form rejected because my NPI number wasn't in box 32, but the first rejection said nothing about my NPI number missing.  (Again, it's in box 33 anyway).  

So, I'm waiting for all my October claims to bounce back, which seems like a tremendous amount of needless work for Medicare and a mild headache for me, and an unfortunate delay for my patients who count on timely reimbursement from Medicare.  Yes, yes, I know, this is why you've opted out.  I just can't get there without feeling guilty.

Wednesday, October 14, 2015

Preauthorization Frustration

In a note sent to my congressional senator:

I am a psychiatrist in Maryland  and I have become interested in the issue of the hoops that insurers require physicians to jump through to get preauthorization for medications.  Given that medicine, and psychiatry in particular, is a shortage field, it seems criminal that insurers can require physicians to spend hours requesting preauthorization for medications.  If the process were simple, this would not be so bad, and certainly some medications are quite expensive with cheaper available alternatives, but the process can go for weeks, during which time a patient can't get medications.
There are also many times when physicians are required to make these calls -- often taking 20-30 minutes-- for medications that cost only a few dollars a month -- the obstacles are mindless and they are hurting the delivery of medical care.  
Each state regulates this, but the issue often crosses state lines.  I have been trying to get a medication approved for a patient for weeks now -- I practice in Maryland, the patient lives in an adjacent state, her insurer  is in Iowa, and the pharmacy oversight agency is in Nevada.  I've been required to make multiple calls, all with hold times, where I am asked the same questions and told that the patient does not have medical necessity for the medication.  They ask the same questions at each step and tell me that while the case for the medication is good, they have no leeway to authorize it.  I have communicated with the CMO of the insurance agency who simply confirms that this is the process.

The process is well-illustrated by Danielle Ofri in a New York Times article last year:Adventures in Prior Authorization.  What she doesn't say is that there are no limits or regulation on how long an insurance company can delay or how many hoops can be set up.

I know Senator Cardin is sensitive to mental health issues.  Rep Murphy of PA has a bill in congress -- the Helping Families in Mental Health Crisis Act -- where he discusses the shortage of psychiatrists, but I don't believe it addresses this issue.


And in one of several emails to the health insurer's chief medical officer:

Yes it would be good if this process could be expedited.  I have been trying for weeks to get this medication for this patient.  I spoken to several people at both Catamaran (the pharmacy benefit agency) and Wellmark.  None would give their full names, and none had the authority to approve the medication if certain questions were not answered 'yes' and there was no room for individual consideration.  Yesterday, I saw the patient to get the release sign, and I noticed that the appeal and release are to be mailed (postal mailed that is) to different addresses, and only the release can be faxed.  I am going to assume that there might be some difficulty in getting these to the same place in a timely manner for review, and during this time the patient continues to suffer.  There seems to be no mechanism for electronic submission.  This process has taken now hours of my time, and it has been weeks.  I am going to attach the appeal letter in the hopes that perhaps as medical director you can get it to the correct place.  I will also mail it, and fax the release.  
Apparently I'm not the only frustrated psychiatrist, Dr. George Dawson at Real Psychiatry has plenty to say on the topic here:

Sunday, October 11, 2015

Forensic Psychiatry Steps into the Social Media Age

Regular followers of this blog know that every year about this time I put up a series of posts entitled "What I Learned." The purpose of the posts is to give people a peek inside the annual conference of the American Academy of Psychiatry and the Law as well as some exposure to the kind of topics forensic psychiatrists are interested in. General psychiatry residents may find it helpful, particularly if they are considering a career in forensic psychiatry and if they can't afford to travel to the conference. Our organization, AAPL, is an international group with members from Canada, the UK, Australia, and South America. Our international members deserve to see what's going on, as well.

This year, we will boost our international presence by livestreaming a select number of presentations through the Meerkat mobile app. Here is a schedule of the presentations we will stream. Directions on how to use Meerkat are below. In addition, select AAPL members have volunteered to moderate questions on each presention through Twitter. Hashtags will be announced through Meerkat, Twitter, and slides at the actual presentation. We've never tried this before, and we are all volunteers rather than professional videographers, so there may be a few snags or hitches but overall we're hopeful people will find it educational and fun. The conference begins on Thursday, Oct 22nd and continues through Sunday.

Here's the schedule:

Graham Glancy 
Witness Protection Program: A Matter of Training
Ken Appelbaum
The New APA Guidelines on Correctional Psychiatry
Ryan Wagoner
The Psychiatrist in Peril: Current Topics in Malpractice
Tobias Wasser 
Novel Approach to Teaching Residents About Violence & Safety
Drew Kingston PhD 
The Relationship Between Mental Illness and Violence
Caitlin Costello 
Adolescents and Social Medica: Privacy, Brain Development and Law
Robert Forrest 
Treatment of Transgender Inmates
Rosa Negron Munoz 
Educational Factors Contributing to Juvenile Delinquency
Madelon Baranoski 
Role of Forensic Psychiatry in Veteran Evaluations
Anna Glezer 
Myths and Realities of Women in Prison
Jennifer Piel 
What Gets Judges in Trouble?
Keith Stowell 
Forensic Issues in Emergency Psychiatry
Hal Wortzel 
TBI Update: International Collaboration on mTBI and DSM-5
Stephen Simring 
Forensic Psychiatry and the Death Penalty
Lynn Maskel 
Rock and a Hard Place: Debating Sexual Sadism Diagnosis

Here’s how you use Meerkat:
  1. First, go to the app store, search for “Meerkat app,” and download it.
  2. Meerkat will ask you to type in your phone number for verification. Then, they’ll send you a four-digit confirmation code.
  3. Next, connect the app with your Twitter account. (If you prefer, you can skip this step and check the app out in stealth mode.)
  4. If you don’t want to add friends, don’t connect your accounts. Simply scroll down and you’ll see anyone who’s live streaming right away. Keep scrolling for more.
  5. Search for and follow @AAPL2015. We will have a schedule of streams posted each day. For simultaneous sessions, AAPL members may use their own Twitter accounts which we will announce. You can search for them on Meerkat as well.

This is all a tremendous experiment so I want to thank my colleagues, AAPL, and our viewers in advance for participating. I'm looking forward to your questions, comments, and discussion.

--ClinkShrink AKA @ClinkShrink AKA Annette Hanson, MD Program Co-Chair

Thursday, October 08, 2015

Does psychiatric treatment prevent suicide?

For today's Shrink Rap post, please surf over to Shrink Rap News at http://bit.ly/1VHS6W7

I ask whether psychiatric treatment prevents suicide and interview VA epidemiologist and suicide guru Dr. Robert Bossarte.
Do check it out Here.

Monday, October 05, 2015

Did you take your pill today?

Proteus Digital Health has a device that allows people to track their medication injection.  A sand-grain sized ingestible tracker is built into the pill and the patient wears a sensor patch that monitors ingestion and the physiologic response (heart rate change, etc).  With the patient's permission, the information is communicated to his physician.  The technology has been around for a few years, and the fact is that half of patients take their medications wrong.

So what is new is that Proteus is applying for FDA approval to use their sensor with Abilify, an psychiatric medication. In a news release:

“Today, patients suffering from severe mental illnesses struggle with adhering to or communicating with their healthcare teams about their medication regimen, which can greatly impact outcomes and disease progression,” said William H. Carson, M.D., president and CEO of Otsuka Pharmaceutical Development & Commercialization, Inc. “We believe this new Digital Medicine could revolutionize the way adherence is measured and fulfill a serious unmet medical need in this population. We look forward to continuing working with the FDA throughout the NDA review.”

So what do you think?  Do you want to know if your patient is taking every dose of medication?  Do patients want their docs to follow them this closely?  I'd ask if we're worried about privacy issues, but is there really any medical privacy left to worry about?  Why psychotropic medications?  Shouldn't we be just as concerned with whether patients are taking their medications for diabetes or congestive heart failure?  Or perhaps we could track people who take antibiotics for Lyme disease and see if those who follow the antibiotic regimen exactly have a better outcome than those who don't.   

Some people like technology.  Roy would probably stick those little sensor things in his Flintstone vitamins, if he could.  ClinkShrink would monitor her ice cream consumption with it's physiologic responses (~her pupils get much bigger when she eats chocolate ice cream).  But don't we think that this has the potential --for better or for worse-- to be 'required' of patients to prove they've been compliant with court-ordered treatment.  For some, it might be a good thing.  If you're in treatment as part of a diversionary program with a Mental Health Court, you might want to be able to prove to the judge that you're taking your medications and you got sick anyway -- it wasn't your fault.  But I do think this technology, if approved, may well end up having a role in outpatient civil commitment to require patients to take their medications.

Schizophrenia expert William Carpenter, MD was interviewed for Psych News and he mentioned several concerns:
“The technology can provide important advances in addressing highly prevalent problems in patients adhering to medications,” Kane told Psychiatric News. However, Kane pointed out, major concerns regarding the use of this technology are likely to arise, such as how the information obtained by the device will be protected.

William Carpenter, M.D., a professor of psychiatry and pharmacology at the University of Maryland School of Medicine, agreed.

In addition to issues of privacy, Carpenter told Psychiatric News that convincing people who are already vulnerable to paranoia to take a medication that may be viewed as highly intrusive as well as the potential high cost of the medicine could present additional challenges.

Carpenter described several other questions about the therapy, including how best to determine candidates for the ingestible-sensor medications. Additionally, he said psychiatrists may need to consider questions such as, “Is this an acceptable privacy compromise in an involuntary commitment?” or “Will the device lead to fewer in-person visits with clinicians and reduce the chances for integrative treatment and early detection of relapse?”

Carpenter concluded, “Some [psychiatrists] will be ready for this innovative approach of treating mental illness, and if this device is successful—with little compromise to the patient—the field will embrace it.”
 At this point, it's just too much Big Brother for me.

Thursday, October 01, 2015

Renews your faith in our American medical system

My thanks to Dr. Laurie Cohen for posting multiple pages of bird-related codes on her facebook page.  And yes, Jesse, I'm trying to find codes for chinchilla-inflicted injuries.