Saturday, July 19, 2008

Weekly Psych News Roundup

Being A Good Sport Can Mean Having A Good Life
Many parents can tell you of the life-changing influence sports have had on their kids during difficult times. Martin Jones, a University of Alberta research scientist, told the Edmonton Journal the myriad ways sports teach kids life skills.

Software Developer Dies In Fall
Steven Thomas, the 36-year-old founder of Webroot Software, died of injuries sustained in a fall from Pali, a cliff 1,000 feet in the air above Honolulu. It wasn't explicitly declared a suicide, but Thomas did suffer from bipolar disorder. His wife told that he had been depressed about the wars in Iraq and Afghanistan and thought both the government and space aliens were after him.Sphere: Related Content

Friday, July 18, 2008

The Mentally Ill Sentenced to Misery by Our Indifference

Anyone who has worked in the mental health system can recite a litany of patients who spin through its revolving doors over and over. They become familiar faces and stories, some loved, some disdained.

This subset of patients return again and again for a variety of reasons, but the most common one is noncompliance with medications. This happens often times because of money and access, other times because of flat-out refusal.

Misfortune often laughs at our weakest, and some of these people end up floating face-down in a river after successfully suiciding, or mumbling in the hallways of a state mental hospital where they are psychologically buffed-up to competently stand trial for some bloody violence. The rest? Well, they walk among us.

As I've written in posts past, the mental health system in America is bleeding to death. The causes are most certainly legion, but the hemmorhage can be stemmed by creating law and infrastructure to get the most seriously mentally ill treated. How to do this?

Assisted Outpatient Treatment (AOT)
There's a prima facie impression that only a relative handful of us give a damn about mental health. After all, last week Congress had to pass a law just to push mental health benefits up to par with other medical treatments. Psychiatrists are the lowest paid medical specialists in the nation. Psychiatric programs are often relegated to the farthest corners of medical centers. Mental health staff are often among the lowest compensated employees. Indeed, it can feel like a service begrudgingly given.

Realistically, mental health's black sheep status is more a matter of evasion than indifference, of exasperation than antipathy, although there is a mix of all those. Sometimes they coalesce to create a perfect storm.

Kendra Webdale
On a rainy Sunday afternoon in January 1999, 32-year-old Kendra Webdale was waiting on a Manhattan subway platform. A young man named Andrew Goldstein approached her and asked for the time. Just as the subway train screeched towards them, Goldstein plunged Kendra down to a gruesome death on the tracks.

Andrew Goldstein was one of those caught in the revolving door of mental health. His life had started full of promise as he possessed an exceptional, perhaps beautiful, mind. It was a promise broken, though, when he had first psychotic break as a college freshman.

Diagnosed a paranoid schizophrenic, Andrew went through multiple psychiatric hospitalizations and, in spite of the fact he had assaulted thirteen strangers without provocation-all of them women-and had expressed fears he would act on his violent impulses towards even more women, he was released, again and again.

As you might expect, Andrew had not been compliant with his medications, mostly because of debilitating side effects, and was continually released before he was truly stable.

In the aftermath of this horrific episode, New York passed an Assisted Outpatient Treatment law for the mentally ill and named it Kendra's Law.

Not long afterwards, another tragic incident would underscore the failures of the mental health system, this time 3,000 miles away in California.

Laura Wilcox
On break from Haverford College in 2001, nineteen-year-old Laura Wilcox was working for a few days at a Nevada County mental health clinic. A 41-year-old client named Scott Harlan Thorpe showed up for his appointment on January 10. But to the horror of all around him, he pulled out a gun and opened fire, killing two clinic employees. Laura was one of them. Scott then drove to a restaurant and shot its 24-year-old manager.

As with Andrew, Scott had not been compliant with his treatment, including medications. By the time he went on his shooting spree, he had descended into a delusory hell where he was being tormented and stalked by the FBI. His family stood by, helplessly watching his unraveling, unable to do anything to compel him into treatment.

Like Kendra, Laura did not die in vain, either. Lawmakers California would enact their own AOT law, largely based on Kendra's, and call it Laura's Law.

What It Is
Under AOT, patients with severe and persistent mental illness can be court-ordered into outpatient treatment, rather than leaving it up to them. If the patient fails to show up for treatment, peace officers or field clinicians can bring them to an emergency room. The patient is evaluated for a possible 72-hour involuntary hospitalization (a 5150 in California). For a complete detail of these otherwise complex laws, please visit The Treatment Advocacy Center.

It is money that is the decisive difference between the New York and California AOT structures. New York has a well-organized and funded program. California's until recently had been all talk and no action, a legislative mandate without the cash to implement it. Happily, that is changing as Los Angeles and Nevada counties are now using Mental Health Services Act monies to initiate AOT programs.

Meanwhile, the investment has paid off handsomely for New York, both in societal costs and the toll of human suffering. To wit: A 59% reduction in repeat hospitalizations, a 75% reduction in incarcerations, a 57% reduction in homelessness, and a 53% increase in medication compliance. If that's not enough, the Office of Mental Health's web site features even more impressive data.

Patient's Rights
A subtext, perhaps, to the lack of political and financial will to enforce Laura's Law in California is simple complacency. It has been 36 years since the well-meaning but fundamentally flawed Lanterman-Petris Short Act effectively tied everyone's hands. Compulsory treatment for even the most seriously mentally ill was sacrificed in the name of patient's rights. Hence, a floridly psychotic patient who believes he's the King of Macaroni on a Moon that's made of cheese is considered legally competent to refuse antipsychotic medications. Mind you, I'm not suggesting that we violate or disregard constitutional rights in any way, but to allow severely ill patients to dictate their own treatment appears ludicrous at first blush, and then downright ridiculous in practice.

If you're a patient who has chronic paranoid schizophrenia, 20 or more psychiatric hospitalizations over the last two years, and a pesky penchant for dope on which you spend your entire monthly government check, do we as a society not have a vested interest, if not moral obligation, to force you into treatment? Or, perhaps we just really don't care if you end up dead at 35 behind some Skid Row trash dumpster. One less loser to worry about, right?

Final Thoughts: Rights Can Be Wrongs
The irony is that patient's rights can also be their undoing. Folks with severe mental illness carousel through mental hospital doors because they can't function in monitored settings. They take easy escapes like alcohol and drugs that lead to hard falls such as homelessness and incarceration. They are essentially children and adolescents in adult bodies. They need us to structure their lives, to support them, to help them make decisions, and to give them a time-out when they are spinning out of control.

Continuing with a business-as-usual approach is, in fact, the greatest violation of a mentally ill person's rights we can commit. The AOT laws are a welcome first step for our patients' recovery.

This post was updated on 12/11/2008.

Many thanks to Kristina M. Ragosta, J.D., Legislative & Policy Counsel at the Treatment Advocacy Center for her assistance.

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Thursday, July 17, 2008

An Ovation for Medivation

More good news on the Alzheimer's treatment front today. New research released today and being published in The Lancet demonstrates a significant improvement in people with Alzheimer's taking the drug Dimebon. Patients showed a substantial reduction in Alzheimer's symptoms after 6 months on Dimebon, and even more improvements at 12 months. Dimebon maker Medivation said they hope to have the drug to market in the US in 2010. The drug is also being investigated as a treatment for Huntington's Disease. If you or a loved are affected by Alzheimer's and are interested in enrolling in clinical drug trials, please visit The Connection Study today.Sphere: Related Content

Tuesday, July 15, 2008

Managed Care: Who Pays?

One of the questions I am most frequently asked in my private practice is whether I accept insurance reimbursement. I have always been happy to provide clients with statements so they may seek reimbursement from their health insurance provider.

However I am part of a rapidly growing cadre of mental health professionals who do not accept health insurance. Following are issues I would urge you to carefully consider prior to seeking managed care coverage for your mental health services.

Is My Personal Information Private? If your managed care provider is paying for your treatment, they will review the details of your therapy sessions. In order for them to authorize a handful of sessions, I must provide them with an extensive list of information. If I don’t have it, I am expected to get it.

The information required is extensive: Has the client ever been in therapy before? If so, what was the precipitating event? Why did they terminate the previous therapy? What is the precipitating event now? Do they use alcohol or drugs, illicit or otherwise? Have they ever been medically treated for their psychological issues? What is their marital status? What is their family dynamic? In short, every conceivable detail of your private life is up for discussion between their case manager and me. This information then becomes part of the documentation which follows you throughout life. Should you apply for health insurance elsewhere, you will have the “mentally ill” stigma following you.

Who’s in Charge? As the old saying goes, “He who pays the piper picks the tune.” If a managed care company is footing the bill for your therapy, neither you nor I are really in control. Rather, a case manager, who is given financial incentive (bonuses, raises, promotions) to deny care, has the power to determine when you are ready to cease therapy. This is, of course, why they call it managed care in the first place.

Their focus is “symptom reduction” and once that has been achieved, there is simply no point from their perspective to continue. This is not to say that “symptom reduction” isn’t a worthwhile goal, but it isn’t the penultimate goal of therapy, either. This leads to the third issue of managed care therapy.

Whatever Happened to Happy? To reduce the power of therapy to “symptom reduction” is to undermine it all together. Psychotherapy in its various forms throughout the ages has been the key to personal liberation and fulfillment. Managed care isn’t particularly concerned with the quality of life or whether you’re happy and peaceful; they just want you to be able to have fewer “symptoms.”

These are three of the serious concerns about allowing managed care to manage your therapy. I urge you to consider them carefully.

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Monday, July 14, 2008

What's Next? Plastic Knives?

San Francisco's Suicide Bridge Dilemma

The debate is heating up in San Francisco over how to prevent suicides from the Golden Gate Bridge. Since the Bridge opened in 1937, 1,250 people have ended it all there, 39 of them just last year. This latest round of controversy was sparked by a report from the Golden Gate Bridge, Highway & Transportation District, which offered up ways to tackle the problem. The possibilities? Install a steel net 20 feet below the Bridge's sidewalk. Change out the four-foot pedestrian railings to 12-foot ones. The cost? $50 million.

According to this story from the National Post, a good deal of San Franciscans favor the report's sixth option: do nothing. It may sound callous in some respects, but I happen to agree with this group.

The fact is the $50 million could be put to much better use in funding mental health programs to render suicide unthinkable in the first place. Otherwise, we simply eliminate a method to complete the act. If someone is desperate enough to take the plunge from the Golden Gate Bridge, I can assure you they would find another method if this modern marvel wasn't an option.
If we begin making the means of a suicide plan off limits, where do we stop? Background checks and 10-day waiting periods before purchasing cutlery? Yes, yes, an extreme example, I know. But $50 million is an extreme amount of money to throw at a problem when it's already too late.
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