Shoveling Up the Mess

This went out on a mass email. I liked it and I decided that since the author wants it disseminated, he wouldn't mind being made a Guest Blogger:

According to a report CASA issued this morning, federal, state and local governments spend almost half a trillion dollars every year -- almost 11 percent of their total budgets -- as a result of alcohol, tobacco and other drug abuse and addiction. The worst part is that, for federal and state spending, about 95% of that money is spent "Shoveling Up" the mess created by a failure to provide enough money for prevention and treatment.

That's right. Out of every dollar federal and state governments spent on substance misuse in 2005 (the latest data available), 95 cents paid for the enormous burden of this problem on health care, criminal justice, child welfare, education, and other programs. And only 2 cents were invested in prevention and treatment programs that could reduce many of these costs -- and save lives.

This huge waste of money is hidden in many different budgets, so most of our elected officials don't have a clue about how much alcohol, tobacco and other drugs really cost taxpayers, and how little governments spend to effectively address the problem. Maybe if they knew, they might do something. You can tell them.

Please do two important things today:

• See detailed expenses for Massachusetts and download the report.
  
  
• Send a message to your governor and state legislators urging them to review and act on the report.
  

Our researchers studied all federal, state and local budgets for 2005 using careful, conservative methods to determine how much of each major budget category was directly linked to substance misuse. For example, they determined how much of each state's Medicaid and other health care expenses were due to one of over 70 medical diagnoses that are caused or made worse by alcohol, tobacco and other drug abuse and addiction. They did the same for criminal justice, welfare and other key government budgets. They also identified all government spending on prevention, treatment and research, regulation of alcohol and tobacco products and drug interdiction.

When the numbers are added up, the total is really shocking: 467.7 billion dollars. Spending less than 2% of the federal and state costs for prevention and treatment, and more than 95% shoveling up the mess, is upside down public policy that wastes billions in taxpayer dollars at a time when resources are scarce, and results in untold human suffering.

Our leaders need to make new investments in prevention and treatment now to reduce the awful burden that untreated tobacco, alcohol and drug problems place on our budgets -- and our citizens.

Please act today.

Sincerely,

David L. Rosenbloom
President and CEO
The National Center on Addiction and Substance Abuse at Columbia University

P.S. Please forward this important message to your friends and colleagues today.

Guest Blogger Dr. Gerald Klee on Martin Luther King Jr., Riots and Psychiatric Hospitalizations

Oh, I so wanted to put this up yesterday! A day late, but....

Dr. Klee writes:

Today, April 4, 2008, is the 40^th anniversary of the assassination of Martin Luther King, which was immediately followed by widespread rioting in cities throughout the US . Baltimore was one of the cities most seriously affected by riots. This tragic situation provided an opportunity to study how admissions to public mental hospitals would be affected by such an emergency. The following 1998 article from The Maryland Psychiatrist summarizes a report by Klee and Gorwitz in Mental Hygiene, Vol. 54, No. 3, July, 1970. The findings, though limited are quite interesting and counterintuitive. For example, psychiatric admission fell during the days of crisis, while General hospitals reported increased admissions of patients with delirium tremens during the same period.

It occurs to me that this story may still be relevant. How well prepared is our present health care system to handle the effects of future civil emergencies.

Riots and Mental Illness

by Gerald D. Klee, M.D. Editor

The Maryland Psychiatrist [Spring/Summer 1998; Vol. 25 No. 1]

Psychiatric Hospital Admissions During The Baltimore Riots of 1968

How would a widespread civil emergency affect psychiatric hospital admissions? Would they go up or down? Would there be differences in demographic characteristics or diagnoses of those admitted? Our efforts to make predictions may be more successful if we have access to biostatistical data from previous events.

The Baltimore Riots of 1968 provided an unusual opportunity to conduct such a study in Maryland.¹ Following the assassination of Dr. Martin Luther King, Jr. in April of 1968 there was rioting in more than 130 cities in the U.S. Baltimore was one of those most seriously affected, with widespread rioting, looting, and burning during the four-day period from Saturday, April 6th to Tuesday, April 9th. The National Guard was mobilized and a curfew was imposed in the city and adjacent areas. Many arrests were made. Daily life was affected in many ways for nearly all residents of the area, black, white, and others.

Events of this magnitude were bound to have many effects on mental health. Soon after the riots occurred, Klee and Gorwitz studied the effects they had on mental hospital admissions.¹

Summary of Methodology and Findings

Our data were obtained from the Maryland Psychiatric Case Register, a ten year (1961-1971) joint project between the Biostatistics branch of the National Institute of Mental Health and the Maryland Department of Mental Hygiene. I was the psychiatric consultant to the project. There was an active psychiatric advisory board with representation from the Maryland Psychiatric Society (MPS). With the exception of office visits to private psychiatrists, all psychiatric admissions and discharges in the State were reported to the Case Register. In this investigation, admissions from Baltimore City to the three state hospitals serving the area were studied. In addition to the four days of the riots, periods of two weeks preceding and following the riots were examined. The number of Baltimore City admissions during the two-week period before the onset of the disorders and after their conclusion did not differ markedly from comparable figures for the prior year (1967). There were distinct differences in admission patterns during the four-day emergency, however, both as compared with the preceding and the following time periods and also with the comparable period of 1967.

At that time, Maryland ’s psychiatric hospitals had been experiencing a consistent increase in admissions of approximately 10% per year. (The revolving door was already in motion.) While this pattern continued during the pre and post riot periods, there was a sharp drop in admissions during the four days of crisis. In 1967's comparable Saturday-Tuesday period, there was a total of 65 admissions to these hospitals. Adding the noted 10% increase brought the number of expected admissions to 71, but the actual number of admissions dropped to 50. Further variations were found on the basis of race and diagnosis as well as place of residence. While there were 27 black admissions for the four-day period in 1967, this decreased to 18 in 1968. The comparable figures for white residents were 38 and 32. Thus, while a drop in admissions was noted for both races, this decline was more marked for blacks. In 1968, 31 of the 50 patient admissions were diagnosed as alcoholic as compared with only 26 of the 65 admissions in the prior year.¹ Concurrently, there was a sharp decline in admissions with psychotic diagnoses (9 in 1968 versus 24 in 1967; statistically significant, using Chi-square test).

In 1967's comparable Saturday-Tuesday period, two thirds of the 65 admissions were from inner city areas where much of the rioting occurred in 1968. During the 4 days of disturbances, however, only half of the 50 admissions were from this part of the city. Some of the admissions were related to the civil disturbances. For example, some patients were picked up by the National Guard for violating curfew and were found to be mentally disturbed.

The data presented are one-dimensional and represent only a fraction of psychiatric episodes that may have occurred during this period. We have no information on the number of cases dealt with solely by the police and the jails. We did not examine short- and long-term mental health effects that did not result in treatment episodes.

While the sample in this study was small and not all of the comparisons were statistically significant, the results show interesting trends and are counterintuitive.

Comment

The study provides an interesting vignette of a major historical event in Maryland history. One would expect to observe changes in psychiatric admission rates during a widespread civil disturbance affecting nearly every aspect of life within the city. It is unlikely that anyone could have predicted a drop in admissions and the other changes that occurred. In hindsight, there are many possible explanations for the findings. For example, the rise in admissions of alcoholics was thought to be related to sudden curtailment of supplies of liquor as liquor stores and bars were closed. General hospitals reported increased admissions of patients with delirium tremens during the same period. Other civil emergencies may occur in the future. How well prepared will the psychiatric system be to deal with them?

1. Effects of the Baltimore Riots on Psychiatric Hospital Admissions; Gerald D. Klee, M.D. and Kurt Gorwitz, Sc.D.; Mental Hygiene, Vol. 54, No. 3, July, 1970

Topamax Effective in Reducing Heavy Alcohol Drinking

JAMA has an article this week by Bankole Johnson, et al., showing the anticonvulsant Topamax (topiramate) to be effective in reducing percentage of heavy drinking days, from 82% in the placebo group to 44% in the Topamax group.

This was a double-blind, placebo-controlled, 14-week study, using 371 study participants. Dose range was 50-300 mg daily. Side effects included tingling sensations, changes in taste, loss of appetite, and impairments in concentration. Mean daily dose was 171 mg/day. They started with 25 mg/d for Week 1, then 50 mg/day for week 2, and increasing by 50 mg weekly (in divided morning and night doses) to the maximum of 300 mg/d.

This may be a good approach to helping some people reduce drinking, especially folks who might also have bipolar disorder, which is sometimes also treated with Topamax.

"Our study had 3 limitations. First, while the pattern of adverse events was similar to that found in our previous study,3 the more rapid titration was associated with decreased study adherence with taking the medication. Previously, when topiramate was titrated over an additional 2 weeks (ie, over 8 weeks rather than 6 weeks), retention rates were similar between the topiramate and placebo groups. Clinical sites least familiar with topiramate experienced more difficulties with retention, whereas completion rates among some experienced groups approached 90% (data not shown). We advise clinicians to use the slower titration schedule and to provide participants with focused education on managing emergent adverse events to maximize adherence with taking the medication. Second, as with most clinical trials in the alcohol dependence field, enrolled participants have to meet criteria enabling the conduct of a safe study. Because this cohort is often relatively healthier and perhaps more homogeneous than the general population of all those seeking treatment for alcohol dependence, our ability to generalize without restriction from this trial to clinical practice is limited. Third, this study did not have a follow-up period, so we could not determine whether, how many, and at what interval participants would have relapsed following medication withdrawal. Nevertheless, with respect to how people fare, on average, following treatment for alcoholism in a clinical trial, a meta-analysis of recent studies has shown that, even after a single treatment event, most can show substantial reductions in drinking up to 1 year afterward.

Our finding in this study that topiramate is a safe and consistently efficacious medication for treating alcohol dependence is scientifically and clinically important. Alcoholism ranks third and fifth on the US and global burdens of disease, respectively. Discovering pharmacological agents such as topiramate that improve drinking outcomes can make a major contribution to global health. Because topiramate pharmacotherapy can be paired with a brief intervention deliverable by nonspecialist health practitioners, a next step would be to examine its efficacy in community practice settings."

What I Think About Paris Hilton

I'm really not one for celebrity gossip but this news (and I use the term loosely) item had some good correctional teaching points so I thought I'd address it. Besides, it's just a matter of time before somebody drops a question to My Three Shrinks asking my opinion about Paris Hilton and her jail status.

So here goes:

Looking at this from the Sheriff's viewpoint, I can imagine what was going through his mind. He's got a new inmate who is:

1. a high profile case
2. a previously upstanding citizen
3. crying, distressed and not eating
4. has a known mental disorder (in treatment at arrest)
5. has an active substance abuse problem
6. is in isolation in a single cell
7. is serving a relatively short sentence
8. is within 24 to 48 hours of incarceration

Egad. The next thing this Sheriff is going to imagine is Paris Hilton hanging dead in a jail cell. She has eight separate risk factors for a correctional suicide and it is not good to have a dead celebrity in your facility. Ideally, the proper intervention would be to get her referred for crisis intervention services as quickly as possible. Educate her about what to expect and how the incarceration will run. Get her referred for psychiatric evaluation and pharmacology, if indicated. If all else fails, use suicide observation to preserve safety. I don't know the LA jail or what resources they have; given her relatively short sentence the Sheriff may have felt the more efficient alternative was to release her to home detention.

Home detention is a good tool used to reduce institutional crowding but it is limited to people with relatively short times left on their sentences and to non-violent offenders. Given that she only had less than a month to serve, keeping her in jail was a waste of space. In Charm City she probably would not have been incarcerated for a first probation violation; I think she probably was treated more harshly than the average defendant. Maybe this was because of her celebrity status or maybe she didn't present herself well in court. In our prison system the decision to put someone in home detention is made without judicial input; it's the institution's perogative to assign someone there.

She was being kept in a single cell because of her celebrity status, but she was seen crying and not eating there. Most completed correctional suicides are done by inmates in single cell status. The facility would have had a reasonable concern about maintaining her safety under these circumstances. One option would have been to put her on suicide watch involuntarily, but again this involves a fair amount of embarrassment and discomfort to the person you're doing this to. I understand she is now housed in a special needs unit where she is being monitored, another reasonable alternative. The term "special needs unit" refers to a specific tier or placement within a facility for vulnerable inmates who require therapeutic monitoring. It is not the same as protective custody in that a special needs unit is controlled and regulated by mental health staff. People with chronic serous mental illnesses or developmental disabilities may be housed on a special needs unit. Every facility does not have a special needs unit; they usually just exist in larger (over 500 beds) facilities so your average small local county jail may not have one.

So that's what I think. I'm sure she'd be welcome back at the Charm City zoo or the local television station anytime. As long as she doesn't drink.

Clin Psyc News notes: May 2006

• Ritalin patch: I expect to see this a lot in nursing homes. I've seen methylphenidate make a huge positive impact on older depressed folks, and a patch form of administration makes it easier. But, it's another one of those dang off-label issues that's flaring up lately.
  
  
• 4.6% Medicare cuts next year: Will this ever get fixed? Locally, I hear of folks having a hard time finding psychiatrists who will even take Medicare. It used to be one of the easiest to participate with... no multipage treatment plans, etc. But practice costs increase every year, and we cannot make up the difference by seeing more pts (although I hear there have been some "creative" docs who have learned how to squeeze 50 90807s in a 24-hour day... no, thanks).
  
  
• Top 10 Psychiatrist Diagnoses: Something is wrong with this picture. The #1 dx is 296.2 (single episode major depr). I would expect recurrent episode major dep to be #1. And all of "Anxiety states" is only #3? I don't think so. The data come from Verispan's survey of 162 psychiatrists. GIGO.
  
  
• Don't flush your fluoxetine: Says to advise your pts on how to dispose of old pills, but does not say what to tell them. I used to tell them to flush them, but now I say to either return to pharmacy. It seems that flushing has led to high drug levels in the water supply.
  
  
• Prazosin reduces PTSD nightmares: This is new to me. Alpha-1 antagonists apparently reduce sleep problems and nightmares in PTSD. [PubMed]
  
  
• Vivitrol: I saw an ad for this recently approved i.m. form of naltrexone (it was going to be named Vivitrex, but I guess this was too close to some other name). Even if there is some efficacy data, this drug will go nowhere. Why? $695 per injection! Are folks gonna pay $22/day to be sober? It's cheaper to stay drunk! Cephalon blew it. I can only imagine that the market they are going after is the court-ordered treatment market. If they hit that one, they will have a blockbuster on their hands, because it is worth $22/day to stay out of jail. (The number of ad-blogs for this drug are incredible.)