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.

 

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?

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.

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 --  

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:

Peter D. Kramer ‏@PeterDKramer Oct 20

Psychotherapy helps in schizophrenia = what psychiatrists in my cohort have always believed, as a guide for practice http://nyti.ms/1RlIfnv 

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.

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.

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:

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:

Thursday 8:00-10:00	Graham Glancy  Witness Protection Program: A Matter of Training
Thursday 10:15-12:00	Ken Appelbaum The New APA Guidelines on Correctional Psychiatry
Thursday 2:15-4:00	Ryan Wagoner The Psychiatrist in Peril: Current Topics in Malpractice
Friday 8:00-10:00	Tobias Wasser  Novel Approach to Teaching Residents About Violence & Safety
Friday 8:00-10:00	Drew Kingston PhD  The Relationship Between Mental Illness and Violence
Friday 10:15-12:00	Caitlin Costello  Adolescents and Social Medica: Privacy, Brain Development and Law
Friday 10:15-12:00	Robert Forrest  Treatment of Transgender Inmates
Friday 4:15-6:15	Rosa Negron Munoz  Educational Factors Contributing to Juvenile Delinquency
Saturday 10:00-12:00	Madelon Baranoski  Role of Forensic Psychiatry in Veteran Evaluations
Saturday 2:15-4:00	Anna Glezer  Myths and Realities of Women in Prison
Saturday 2:15-4:00	Jennifer Piel  What Gets Judges in Trouble?
Saturday 4:15-6:15	Keith Stowell  Forensic Issues in Emergency Psychiatry
Sunday 8:00-10:00	Hal Wortzel  TBI Update: International Collaboration on mTBI and DSM-5
Sunday 8:00-10:00	Stephen Simring  Forensic Psychiatry and the Death Penalty
Sunday 10:15-12:15	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

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.

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.

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.

Welcome to ICD-10

Today is October 1, 2015, and the day set for the long-awaited change in the system used to code medical and surgical diagnoses.  Say good-bye to the 17,000 ways that the International Classification of Diseases 9 let you be sick or injured, and now we have 70,000 new ways for all those events.

In psychiatry, it shouldn't be too bad, and I'm planning to spend my day in the office updating my computer.  The psychiatry blogger PsychPractice was kind enough to make a cross-over chart, and I'm hoping that will be helpful.  If it might be helpful to you, here is the link:

http://psychpracticemd.blogspot.com/p/blog-page.html


For others, it may not be such an easy day.  If you're having angioplasty today, yesterday your doctor had a choice of one code.  Today, she has 845 options, so do be patient with her, it's a big menu to choose from.  

There were jokes on Twitter about codes that would differentiate between being bitten by a duck in a thong or being bitten by a duck while wearing a thong.  Here at Shrink Rap, where the duck has been our long-time mascot, we don't think that's at all funny.

If you'd like a sample of some of the new codes, however, there is something for everyone.

For the creative types:
Y93.D1 Activity, knitting and crocheting

For the more active souls:

V91.07XA Burn due to water-skis on fire, initial encounter

 For those who can be a bit klutzy:

T71.231D Asphyxiation due to being trapped in a discarded refrigerator, accidental.  I couldn't find the code if someone was trapped in a refrigerator that hadn't been discarded.

And for those who are just really unlucky:

V9542XA Spacecraft crash injuring occupant – 

The codes can be very specific:

S30.867A Insect bite (nonvenomous) of anus, initial encounter

And we don't want ClinkShrink to feel left out, so there is

Y92.146 Swimming pool of prison as the place of injury

(And I imagine ClinkShrink will certainly be spending her day checking on the safety features of all those swimming pools in the correctional system here in Maryland)

Finally, there really are duck-related injury codes and they are kind enough to differentiate whether the patient is struck by a duck W6162XA or bitten by a duck W6161XA.  I suggest that you not do anything to provoke the duck.

Humor Alert brought to you by Rachel Griffin, graduate student

Sh*t People Say to People with Mental Illness

#GiveStigmaTheBoot

In case you missed it, the billboard above, sponsored by designer Kenneth Cole, has been the source of a lot of angst.  Presumably, Mr. Cole meant to point out that people with difficulties have trouble accessing mental health care ( ~so true), but instead the message blames people with mental illness for gun violence.  It's both wrong and stigmatizing, and the American Psychiatric Association understandably asked to have the billboard taken down and started a #GiveStigmaTheBoot campaign.

I want to point out an inconsistency in the APA's endorsements.  Representative Tim Murphy has proposed an overhaul of our national mental health services from the top down.  Many of Murphy's proposals in his Helping Families in Mental Health Crisis Act are admirable and have the potential to decrease repetition of oversight, and hopefully to change the way psychiatric services are delivered to those who need them most.  However, the bill was put forth in response to the Newtown tragedy where a disturbed young man killed 27 people, including 20 young children.  Murphy repeatedly says that something needs to be done about our nation's mental health services before more such tragedies occur, and that this is his promise to the parents of the children who died at the hands of a disturbed gunman.

Murphy's bill creates incentives for court ordering patients to outpatient treatment, also called Assisted Outpatient Treatment or AOT -- a measure that has been used in some states for people with psychotic disorders who are repeatedly hospitalized for noncompliance with treatment.  Outpatient commitment is a tough one -- it may help some people to get help, but it also infringes on a person's right to determine their own medical care, a civil right we all value.  
  In an article in Behavioral Healthcare on September 4, 2015, "Murphy touts mental health bill on Cleveland visit," Julie Miller writes about Murphy's support of the controversial outpatient commitment bill.   Miller writes:

He believes that if the perpetrators of violent tragedies like Sandy Hook Elementary School and the Aurora, Colo., movie theater had assisted outpatient treatment, the tragedies wouldn’t have occurred. To those who oppose AOT on the basis of personal freedom, he says, “Go talk to the moms from Sandy Hook and tell them that.”

Personally, I'm at a loss here.  From what I've read in a variety of sources: the media, the report of the Connecticut Department of the Child Advocate, and live-streamed testimony from the Aurora hearings, neither of those shooters had ever had a single psychiatric inpatient commitment and neither had a history of violence.  No one knew these young men had planned these atrocities.  The graduate student in Colorado was going voluntarily to treatment, he stopped when he left school and his eligibility for services ended.  If his psychiatrist knew he was dangerous, there are laws in place that would have permitted his commitment.  Both young men were diagnosed with anxiety disorders, not psychotic disorders, prior to their shocking crimes.  Simply put, they weren't candidates for Outpatient Commitment, and by making the assertion that outpatient commitment can prevent mass murders, the implication is that the government could knock on your door to see if you are harboring a loner young man who plays videogames and behaves oddly.  These aren't the people who get captured by Outpatient Commitment orders.

Yes, we need better mental health access and more comprehensive services.  But we need them to help people live better lives and suffer less.   Everything about Murphy's Bill as a promise to the parents of the children of Newtown --- that better mental health services will prevent mass murder -- is stigmatizing.   And yet the APA has no campaign against this stigmatizing bill, in fact, the APA wholeheartedly endorses this form of stigma.  

Follow Up on Parity and Tuition Reimbursement Insurance

I recently wrote a post about the discriminatory practices by Dewar Insurance -- a company that offers insurance for tuition reimbursement in case illness prevents a college student from completing the semester.  For some schools, the reimbursement is less and the standard of proof is higher if the illness is a mental disorder. 

The issue was originally brought to my attention by Maryland psychiatrist (and parent) Dr. Mark Komrad, author of  the book, You Need Help, wrote back with what he learned at freshman orientation at his son's college.  

A couple of weeks ago I discovered the lack of mental health parity in the tuition reimbursement insurance available through my son's college. And a few of us did research and found this parity problem common to many colleges, including in Maryland, but not all. Withdrawals for mental health reasons have tuition reimbursement at a lower percentage than "medical" withdrawals. Also, unlike medical withdrawals, mental health withdrawals require two days of hospitalization as part of the eligibility criteria to pay out.

I'm moving my son into college, and had a meeting about this with the directors of Student Accounts and a representative from the Dewar insurance company, the underwriters. I thought I would share some notes from that informative meeting:

• -My son's school is on top of this issue and next year the tuition reimbursement insurance will have full parity for mental health, WITHOUT requirement of hospitalization!!!

• -No family at this college has ever complained before about lack of parity until I raised this--neither prospectively as now, nor when a policy had to be used for mental health reasons! So there was no incentive to change, although the fairly new director of student accounts was troubled and was already taking initiative to change it before I got involved

• -Only about 100 families buy a policy, most don't think they'll ever need it. So there is much interest here and elsewhere in making the policy automatically included as part of the bill next year, but with an option to opt-out. Like with all insurance, the more people who participate, the less expensive the premiums are.

• --There has been a steep rise in withdrawal for mental health reasons nationally just in the last 4-5 years. The majority--about 70%-- of health withdrawals nationally now are for psychiatric reasons. Prior to that they were the minority reason. Nobody is quite sure why that is.

• -Dewar would actually like to offer parity policies but many colleges have not been interested. Again, this is not a particularly popular product so colleges haven't paid much attention to the non-parity status quo that goes back several decades. Many are just starting to notice the non-parity issue now, and are moving to correct it. Dewar is happy to try and make that possible for any of its college customers.

• --This policy places NO extra financial risk on colleges. That is NOT the reason colleges haven't sought parity.

• -Dewar doesn't really challenge doctors notes vigorously. Docs have to fill out a form. There are no internal  "medical consultants" that review and deny coverage--unlike health insurance companies. With the policies that require psychiatric hospitalization, that requirement has been waved in many cases.  It's a holdover from many years ago when these policies were first crafted.

• -For the business model to work for parity,  psychiatric (now the most common cause for intra-semester withdrawal) and medical can't BOTH be covered at 100%. So policies that now cover medical at 100% and psych at 60% will need to be restructured for the two the meet in the middle. Losing that 100% for medical may be one of the inhibitors to change

So, if we are going to go after this parity issue in Maryland, my sense is that it needs to be on a college by college basis to increase their consciousness about this issue, and, for those who have contracted with Dewar, to let them know that this can be potentially corrected.