Raleigh News and Observer
Point of View:
Published: Jun 30, 2006 12:30 AM
CHAPEL HILL - The General Assembly's determination to build three new mental hospitals -- at Butner, Goldsboro and Morganton -- indicates to me that we have now come full circle in mental health services in North Carolina.
About 40 years ago, during the Terry Sanford administration, our state gained national prominence as a model of reform for services for persons with mental illness and mental retardation. This came when we "deinstitutionalized" the mental health service system and moved from a few mental hospitals to a 41-multi-county-area system. It included special Mental Retardation Centers strategically located around the state, backed by local diagnostic, rehabilitation and training programs.
These programs were mostly supported by state and federal funds. Sanford's leadership and subsequent support in the Scott, Holshouser and Hunt administrations brought services to a level of penetration and access no longer enjoyed by our families and communities.
Instead, we have a meltdown in services from our attempts to reduce our tax base and privatize human services in a probably well-intentioned but ill-advised effort to "reform our system for the 21st century."
Now we have two dozen or so "local management entities." This is corporate-speak for "who's on first?" on mental health and developmental disabilities issues. These non-entities are underfunded, understaffed and underhoused for their "customer groups'" needs. Now we are returning to the 1950s strategy of building new multi-floored hospitals, away from the major population areas, and apparently because of the much-needed jobs and the economic jolt that the construction of this archipelago would provide.
No mistake -- residential care and treatment are badly needed as key parts of a mostly community-based service system, but they need to be downsized and more widely distributed and clearly connected to regional coordination centers with the resources necessary to carry out their missions.
And forget privatization. There is no profit in human service. If there is, we have another kind of problem.
(Don Stedman, Ph.D., is a senior fellow with Action for Children N.C., dean emeritus in education at UNC-Chapel Hill and, until his recent resignation, a long-time member of the N.C. Commission on Mental Health, Developmental Disabilities and Substance Abuse Services.)
TEXT Read more!
Friday, June 30, 2006
Raleigh News and Observer
Posted by david at 10:17 AM Permalink
Published: Jun 26, 2006 12:30 AM
No decision on building more state mental hospitals ought to be made before the system's reform is fully funded
For the past five years, North Carolina has been reforming its system of caring for the mentally ill. The goal has been to provide state funds for care that would keep most patients out of rundown state hospitals.
Yet as the system was being rebuilt, state leaders have invested too little money in preventive services for communities. Sadly, the same pattern is being repeated this year.
That history is worth remembering in light of a last-minute proposal, reported by The N&O's Lynn Bonner, to build new hospitals replacing outmoded facilities in Goldsboro and Morganton. House leaders wisely are resisting a rush job. The last thing that North Carolina's mental health system reformers need is a costly distraction from making the fundamental changes work.
A legislative committee overseeing the reform efforts heard ample evidence earlier this year that community-based services were not keeping up with demand. Some private practitioners have been reluctant, understandably, to step in until there is enough money set aside to pay them for their work. As a result, state hospital populations have been rising, along with emergency room admissions of the mentally ill.
The oversight committee figured that $155 million would be needed in the next budget to put the efforts back on track. But neither the Easley administration nor legislative budget writers have been willing to consider more than $105 million. Even the potential savings from closing Dorothea Dix hospital in Raleigh have been redirected to pay for the smaller hospital being built in Butner to replace it.
With that kind of foot-dragging going on, the Senate's call for replacing Cherry Hospital in Goldsboro and Broughton Hospital in Morganton makes some sense. Conditions for patients are intolerable: In Goldsboro, for instance, they sleep four to a room and as many as 32 share a bathroom.
Now, as the House and Senate go about reconciling budgets already passed, some senators see an opportunity to press for replacement facilities in their districts. The reasons to take more time making such a decision are plentiful.
Not only is there little time left for discussion, but no planning for the buildings has been done. Cost-estimates, though, run to $145.5 million for Cherry and another $162.8 million for Broughton. Debt service on that borrowed sum would likely reduce the money available for housing and care of the mentally ill in their own communities.
That's the quality of care North Carolina aspired to five years ago. Back then, patient care at Dix was a scandal and a federal investigation had been launched for possible civil rights violations. Legislators who recall those tense times ought to be demanding a proper budget for carrying out the promised reforms.
Posted by david at 10:13 AM Permalink
Tuesday, June 27, 2006
Tuesday, June 27, 2006
Everywhere you turn, it seems, the state finally is taking a hard look at support for the mentally ill.
The Winston-Salem Journal reported last week that Forsyth County court officials and CenterPoint Human Services have applied to the U.S. Department of Justice's Bureau of Justice Assistance for a $250,000 grant to pay for a special court for the mentally ill.
Under the present system, magistrates have two options: They can send the arrested to jail or to an institution.
So, rather than create a separate, and expensive, court, the Forsyth County model would assign one magistrate to all cases involving the mentally ill and would have a mental health professional on hand to assist, said county Chief Magistrate C. John Phillips.
For minor crimes related to illness, such as accidentally striking someone, it would keep these people out of jail. While lockup could exacerbate a problem, the right treatment could do a world of good. Those arrested for serious crimes still would go to jail.
The program also could help reduce recidivism because for some, treatment is all that is needed. Carl Ekstrom, director of government and community relations at CenterPoint, said he will track the data if the grant is approved.
Phillips said the program would help as well with involuntary commitments. A mental health professional could assist relatives and explain to the magistrate the best course of action.
With an officer on duty to monitor those arrested, patrol officers could return to the streets. Repeat offenders would go through the same magistrate, so he or she would recognize when the patient has run out of chances.
Guilford court officials were examining the idea last year when they received word that the Guilford Center no longer would provide direct care as a result of mental health reform, said Chief District Court Judge Joe Turner.
Applications for the same grant for Guilford County, for $150,000, have been sent, said District Court Judge Wendy Enochs. Meanwhile, arrangements have been made for someone from the Guilford Center to assist once a week with defendants.
Maj. Herb Jackson, court services bureau commander for the county Sheriff's Office, estimated that the mentally ill constitute at least 10 percent of the jail population. With the state's reforms, he said, more of those ending up in jails are mentally ill.
For the many counties trying to help the mentally ill, this is a less costly solution than a separate court. Areas lacking such a program should explore this positive alternative to draconian options. Read more!
Posted by david at 10:22 AM Permalink
Friday, June 23, 2006
Once again, an insanity defense for drowning five kids
Friday, June 23, 2006; Posted: 7:20 p.m. EDT (23:20 GMT)
(CourtTV) -- For the second time since Andrea Yates drowned her five children in a bathtub, her lawyers will attempt to convince a jury she was legally insane when she did the unthinkable.
With its guilty verdict in 2002, a jury in Houston, Texas, seemed to reject defense arguments that a history of mental illness compounded by postpartum depression drove Yates to drown four sons and a daughter, ages six months to seven years.
The same jury that convicted Yates spared her the death penalty, making her ineligible for death at her retrial, which begins this week. An appeals court overturned the guilty verdict in 2005 based on erroneous testimony from a prosecution mental-health expert.
Opening statements are expected to begin Monday.
From the prosecutors trying Yates to the judge presiding over the trial, much remains the same at the new trial. Once again, Yates is pleading not guilty by reason of insanity to three murder counts.
But this time, lawyers say they are equipped with much more information regarding Yates' state of mind to support the contention that she did not appreciate the difference between right and wrong when she drowned the children on June 20, 2001.
On that day, Yates told police she filled up the tub and held each of her children one by one under the water until they stopped struggling. She then placed four of them on a bed in a back bedroom and covered them with a sheet.
Chased son, 7
In the taped police interview, played in her first trial, Yates described how she chased her oldest son, 7-year-old Noah, through the house before drowning him in the tub and leaving his body floating in the water.
She then placed a call to 911 and to her husband, Russell Yates, to report that she needed "help" with her children.
Yates remained emotionless throughout the narrative, even as she told an officer that she began entertaining the idea of killing her children when she realized she had not been "a good mother" to them.
Faced with the burden of proving that, at the time of the deaths, Yates was suffering from a mental disease that prevented her from understanding the difference between right and wrong, defense lawyer George Parnham pointed to Yates' well-documented history of depression and suicidal tendencies.
Her medical records showed that following the birth of her fourth child, Luke, in 1999, she attempted suicide twice and reported hearing voices and having visions.
Her treating physicians, one of whom testified that she was one of the five sickest patients he had seen in his career, diagnosed her with postpartum depression and put her on a regimen of prescription drugs and continued therapy.
In spite of warnings from her doctors that her condition would worsen with the birth of another child, Yates gave birth to daughter Mary in November 2000. Four months later, Yates' father died, an event which precipitated a decline in her condition, according to testimony by her doctors.
At the time of the deaths, Yates had been out of a mental health facility just over a month. Two days before she drowned the children, Yates' treating physician had lowered the dosage of her antidepressants based on her self-reporting that her condition had improved.
In her confession to police, Yates said that her intent was to kill her children and asked when her trial would be, leading prosecutors to surmise that she appreciated the wrongfulness of her actions.
At her trial, the state's sole mental health expert, Dr. Park Dietz, testified that her call to 911 and her mention of a trial implied she knew that what she had done was wrong.
A consultant for the television drama "Law and Order," Dietz also testified that, in the weeks before Yates killed her children, an episode had aired in which a mother drowned her children in a bathtub and was later found not guilty by reason of insanity.
In its closing argument, the prosecution seized upon the testimony and suggested that Yates, who was known to watch "Law and Order," caught the episode and replicated the events as a "way out."
After Yates was convicted, her lawyers discovered that no such episode existed, and appealed to the state's highest court.
Justices on the Texas State Court of Appeals sided with the argument that Dietz's testimony constituted a grave bias that wrongly influenced the jury's verdict, and ordered a new trial.
Parnham said Yates still suffers from delusions and visions, especially around the anniversary of the deaths of her children.
If convicted, Yates faces life without parole. Even if she is acquitted, however, she faces a substantial period in a mental health facility until her condition improves. Read more!
Posted by david at 5:12 PM Permalink
Thursday, June 22, 2006
Justice Department investigators cite misdiagnosis, misuse of drugs and violence.
From The Los Angeles Times by Lee Romney, May 5, 2006
The state mental hospitals in San Bernardino and Atascadero are plagued by widespread problems, including inadequate diagnoses and treatment, improper and excessive medication, and a boilerplate approach to care that leads to unnecessarily prolonged hospitalization, according to scathing investigative findings released Thursday by the U.S. Department of Justice.
Investigators also found that San Bernardino's Patton State Hospital suffered from high rates of patient-on-patient violence, repeated suicide attempts by hanging and care so inadequate that visible signs of irreversible side effects from psychotropic medications had escaped notice.
The findings were made public two days after federal officials sued California's mental hospital system and filed a detailed consent decree designed as a court-monitored road map for reform over the next five years.
Although only Metropolitan State Hospital in Norwalk and Napa State Hospital in Napa were named in the lawsuit and consent decree, federal and state officials say both documents will be amended to include Patton and Atascadero State Hospital in the corrective plan.
The litany of systemic breakdowns did not surprise hospital administrators or state Department of Mental Health officials. Rather, they are many of the same problems detected by federal investigators when they visited Metropolitan in 2002 to launch the first of four civil rights probes.
Rather than wait for the federal probe's findings, state officials promptly hired a former U.S. Justice Department consultant to help them convert California's outdated system to a new model of care that involves patients more actively in their recovery.
"For the last two years, we were basically doing what we thought would meet their needs," Patton Executive Director Octavio Carlos Luna said of federal justice officials who are charged with safeguarding the constitutional rights of mental patients. "Basically now they are fine-tuning the direction they think we should be going. … It's all constructive criticism."
In a statement, Atascadero's clinical administrator, David Bourne, called the findings "painful when balanced against what we believe to be our good reputation," but "an important milestone" that would help improve the hospital.
Patient's rights advocates were cautiously optimistic that the federal attention would lead to reform. "The consent degree, at least on its face, is a positive step and these investigations are a positive step," said Matt Fishler, a staff attorney with Protection & Advocacy Inc., a state contractor that advocates for mental patients' rights. "The key is going to be how it's implemented and what kind of oversight there's going to be."
The bulk of patients at Atascadero and Patton have entered through the criminal justice system. While many are docile, others are violent or sociopathic, presenting a challenging patient mix. The system has also been struggling with staff shortages and forced overtime, a burden that investigators noted in their report on Atascadero.
Despite the concerted efforts at reform, the investigative findings show just how far the hospitals are from meeting accepted standards of care.
Among them: initial assessments are "cursory and not individualized," and lead to inappropriate prescriptions and treatment planning; pharmacy, nursing and other services are subpar; and inappropriate sexual relations occur between patients and staff.
Rather than tailoring treatment to individual patients, the findings noted, Atascadero focuses on "symptom reduction," contributing to "a perpetual cycle of chronic disability and repeated hospitalization." Short-term medications to control behaviors are administered in place of treatment, and rehabilitative therapy "is essentially diversionary, such as playing 'bingo.' "
Although the report praised many staff as "dedicated," it chided the medical and psychiatric departments for excluding other professionals - such as psychologists and other therapists - from diagnoses and treatment decisions. It also said nurses often lack knowledge of mental health diagnoses and move between units so often that they are not familiar with individual patients.
Gregory Peters, 48, a former Atascadero patient who has been moved to the state's newest facility at Coalinga, welcomed the findings and consent decree.
"We've been working a long, hard time on this," he said. "They overused the seclusion room for a control mechanism for people who were just not going along with the program. They overused the restraint room for the same thing. … They put mental disorders on you that aren't even close."
The findings revealed seemingly deeper and more harmful breakdowns at Patton, including a long-standing problem with illegal drugs and inappropriate sexual conduct, and cursory psychiatric assessments that routinely lead to misdiagnoses.
Vulnerable patients are "on high doses of psychiatric medications without a diagnosis that would justify such use, nor any evidence that the prescribed dose provides any benefit to the patient," the report noted.
Investigators were startled in December when they observed Patton patients with tardive dyskinesia, a generally irreversible side effect of long-term use of haloperidol and other psychotropic drugs. Symptoms can include grimacing, tongue protrusion, rapid blinking, and movements of arms and legs.
Hospital staff "failed to detect these symptoms and even consider prescribing other medications with less harmful side effects," they wrote.
Luna said investigators brought only one such patient to his attention, though he said, "One is too many. We're setting up systems to review that."
Investigators also noted that short-term medications were repeatedly used "as a form of chemical restraint, but without the documentation and monitoring that use of chemical restraint requires." Physicians were often not notified of the medications, even though some patients received them every four hours.
The frequency of such medications is now being monitored more closely systemwide, Luna said.
Perhaps Patton's biggest problem, however, was safety, with more than 500 patient-on-patient assaults noted in the six months before the December investigative visit, two 2005 homicides, and a series of suicides and suicide attempts by hanging "that appear to be part of a trend."
Luna said staff in the last month had begun moving wardrobe lockers in the bedrooms to more visible locations, because patients had used the furniture to hang themselves or as cover for assaults. The lockers, he said, would be replaced with shorter ones.
Still, investigators criticized the hospital for its lack of insight into such problems. Investigations merely document harmful incidents, rather than explore their cause, the findings noted. They also routinely exonerate staff members, a result that investigators said "strains credulity and suggests that such reviews are not reliable."
Investigators even criticized Patton's attempt to shift to the so-called "recovery model" and use cutting edge "treatment malls" where patients attend a range of vocational and life-skills classes as a means of self-empowerment. The classes often do not address patients' specific needs, patients are sometimes assigned to classes they did not select and class leaders lack training, the report noted.
Patients who refuse to participate are sent to the "enhancement room," a crowded enclosure where they are required to sit in chairs without any activity for the duration of the session.
"This is not therapeutic and may aggravate the condition of patients already in distress," investigators noted.
Still, Luna called the findings "as positive as a negative thing can be."
"Up to this point we've been working on what we think we ought to be doing," he said. "Now we have some rules to focus on."
Posted by david at 6:41 PM Permalink
Saturday, June 17, 2006
Non-fatal, self-inflicted injuries by adolescent and young adult females are major public health problems and researchers have found physiological evidence that this behavior may lead to a more serious psychological condition called borderline personality disorder.
University of Washington psychologists have discovered that adolescent girls who engage in behaviors such as cutting themselves have lower levels of serotonin, a hormone and brain chemical, in their blood. They also have reduced levels in the parasympathetic nervous system of what is called respiratory sinus arrhythmia, a measure of the ebb and flow of heart rate along with breathing.
"A low level of this measure of the parasympathetic nervous system is characteristic of people who are anxious and depressed and among boys who are delinquent. But this is the first study to show it among adolescent girls who engage in self-harming behavior," said Theodore Beauchaine, UW associate professor of psychology.
The findings come from a study that also uncovered sharp disparities in the number of self-harming events and suicide attempts reported by the girls and their parents.
The research, headed by Sheila Crowell, a UW psychology doctoral student, focused on girls because self-harming behavior affects females far more often than it does males. The study included 23 girls, ages 14 to 18, who engaged in what psychologists call parasuicidal behavior. Participants were included if they had engaged in three or more self-harming behaviors in the previous six months or five or more such behaviors in their lifetime. An equal number of girls of the same ages who did not engage this behavior were enrolled as a comparison group.
The adolescents in the parasuicide group reported far more incidents of self-harming behavior than did their parents. Individuals engaged in this kind of behavior between 11 and 839 times. Their parents, however, reported a range of 0 to 205 incidents. Similarly, the girls reported more than three times the number self-harming behaviors with intent to die, 310 events versus 90, than their parents did. However, the girls and their parents were very close on the number of times an adolescent required medical attention.
Twenty of the girls, or 87 percent, reported at least one attempted suicide, but Crowell said this number is not that surprising in this population.
"You need to understand a person's intent and the lethality of their attempts," she said. "Did they take a small number of Tylenol or were they holding a loaded gun to their head?"
She noted cutting was the most common self-harming behavior in which the girls engaged. Eight-two percent of girls used instruments ranging from paper clips to kitchen knives and razors with the intent of hurting themselves.
"These attempts have to be taken seriously," said Beauchaine. "These girls may be really at risk for later suicide, and in the long term there needs to be studies of the progression of self-harm attempts."
To find physiological markers of self-harming behavior, the UW researchers showed both groups of adolescents a three-minute film clip from the movie "The Champ" depicting a boy with his dying father. Previous studies have shown the film can induce sadness. A number of different psychophysiological measures were collected from each of the girls before, while and after viewing the film clip. Following the viewing a small blood sample was taken to measure whole-blood serotonin.
The girls who engaged in self-harming behavior had lower levels of respiratory sinus arrhythmia in their parasympathetic nervous system while watching the film clip. These measures, the researchers argue, support the idea that the inability to regulate emotions and impulsivity can trigger self-harming behavior.
"This research supports the primary theory that borderline personality disorder is caused by an inability to manage emotions. These girls have an excessively strong emotional reactions and they have extreme difficulty in controlling those emotions," said Beauchaine. "Their self-harming behavior serves to distract them from these emotions."
Borderline Personality Disorder is far more serious than self-harming behavior and people with the condition have a very high suicide rate. An estimated 5.8 million to 8.7 million Americans, mostly women, suffer from borderline personality disorder. People with the condition have a multiple spectrum of disorders that are marked by emotional instability, difficulty in maintaining close relationships, eating disorders, impulsivity, chronic uncertainty about life goals and addictive behaviors such as using drugs and alcohol. They also have major impact on the medical system by being among the highest users of emergency and in-patient medical services.
Co-authors of the study are Elizabeth McCauley, UW professor of psychiatry and behavioral science; Cindy Smith a former psychiatrist at Children's Hospital who is now in private practice; Adrianne Stevens, an incoming UW psychology graduate student, and Patrick Sylvers, a former UW student who is now a graduate student at Emory University. The study, published in the journal Development and Psychopathology, was funded by Seattle Children's Hospital, the National Foundation for Suicide Prevention and the National Institute of Mental Health.
Posted by david at 6:10 PM Permalink
Tuesday, June 13, 2006
by PEGGY MANNING
Senior staff writer
The purpose of the state's ongoing mental health reform was supposed to be to give the public a choice of providers and to make it easier to access those services.
However, someone needing mental health services may find the search to be a little daunting and confusing.
First, there's the problem of knowing where to look. A telephone directory listing for psychiatrists refers the person to the section on physicians. That listing contains two names, including a toll-free number for the Smoky Mountain Center for Mental Health, Developmental Disabilities and Substance Abuse Services and one private provider.
A listing for psychologists also has two names - the Smoky Mountain Center and a private provider.
If that person looked up mental health, they would find only two listings. One is a listing for Park Vista, a group home, and again the other is the Smoky Mountain Center.
If, however, that person turned to the section for counselors, they would find a list of 15, including the Smoky Mountain Center.
Prior to the onset of the mental health reform movement, the Smoky Mountain Center housed offices for some mental health providers. After the state mandated that local management entities (LME) be separate from the providers, Smoky Mountain Center became the LME and providers branched out to become Meridian Behavioral Services. Many of their former employees began working for Meridian. Jerry Coffey, a 33-year psychologist now at Sylva Clinical Associates, once worked with the Smoky Mountain Center. He and other area counselors say most people are not aware they can contact other counselors besides those in the Smoky Mountain Center system.
“If a counselor is not in the Smoky Mountain Center network, they are excluded from the list of providers that the center distributes to consumers,” he said.
“The reform plan is good; the execution is weak,” he added.
Coffey said he and other mental health practitioners asked to be involved in early efforts to establish best practices for mental health treatment, but said they were not able to be part of that process.
A group of about 40 mental health practitioners even formed the Western North Carolina Behavioral Health Care organization when they saw that things were not going as well with the reform as they expected. “We tried to figure out the state's agenda, but it didn't go anywhere,” Coffey said.
Susan McKinnish, a counselor for more than 20 years, insists that in order to make the reform work, patients must know what services are available and what their rights are as patients.
“I and other mental health practitioners can see Medicaid patients and patients can call our office for an appointment. They do not need an assessment from the Smoky Mountain Center, nor do they need a referral,” McKinnish said.
She also points out that if a patient needs medication, their family doctor can usually prescribe it unless they have a severe mental condition that requires the expertise of a psychiatrist.
McKinnish started as a social worker in 1982, and earned her master's degree in 1990. She has been in private practice for six years.
McKinnish and another Haywood County counselor, Martha Teater, also tried to work with the Smoky Mountain Center at first. But, both said they were not getting many referrals and they found working with the new system cumberome and problematic. They are now among the group of many counselors working independently of the LME.
“There was a lot of confusion at first,” said Teater, who has been a licensed marriage and family therapist for 18 years.
Communication between the LME and private providers has been poor, she said, citing the example of when she referred one of her young patients to the Balsam Center and then later found out that the children's unit had been closed.
Teater, McKinnish and Coffey say they rely on word-of-mouth references and return clients to build and maintain their businesses.
What private mental health practitioners would like is to see a level playing field, Teater said.
“The county does not even disburse money equally among providers. Meridian is in private practice just like us,” she said.
One segment of the population that is suffering more than others seeking mental health services is the uninsured, Teater said.
“They can't afford the price of counseling. The Good Samaritan Clinic is trying to meet the needs of the uninsured and is expanding their mental health services, but there is still a need in the community,” she said.
“The changes in the mental health system haven't really impacted my private practice,” said Dan Yearick, a Waynesville-based counselor. “I continue to have clients who pay privately or who use health insurance to reimburse me for my services.”
In addition to being in private practice, Yearick is also the mental health coordinator for The Good Samaritan Clinic. The clinic serves those who are uninsured for both medical and mental health needs.
“As the state system continues to restrict services, we are finding there are no options for individual therapy for adults who are uninsured. We (the Good Samaritan Clinic) continue to work to find ways to provide service to those in need of mental health services,” Yearick said.
“Currently through contracting with therapists in the community who are willing to receive a very small fee-for-service, as well as through the use of graduate students in the counseling program at Western Carolina University, we are providing individual therapy for patients who are otherwise neglected by the system. This is an ever-growing need, and we are always adjusting to meet these needs,” he said.
While there are numerous choices of counselors, there is a need in the area for more psychiatrists, Teater, Coffey and McKinnish agree.
“The county and the hospital need to make an effort to recruit more psychiatrists to Haywood County,” Coffey said.
“Considering the traditional lack of resources in our area, the rise of Meridian Behavioral Services from the ashes of the Smoky Mountain Center Area Authority as we knew it before reform, was basically our catchment area's answer to mental health, developmental disabilities and substance abuse services provision capacity,” said Ed Seavey of Waynesville.
Seavey served on a consumer advocacy council until he said he was kicked off for working with other mental health providers to let people know they can have a choice.
“It was pretty much expected, and apparently accepted, that the Smoky Mountain Center and Meridian Behavioral Services were indivisible. From the onset, it became obvious that consumer 'choice' would be which MBS staff you would be served by,” Seavey said.
“However, the continued sharing of phone services by SMC and MBS is not friendly to an environment that could eventually support a true diversified private provider network as prescribed by the state plan,” he said.
Seavey said he again ran into the phone situation in September 2005.
“I was calling the Jackson County MBS administration to try and help a single mother find information about services that were not readily available or could not be made clear in Haywood County. Finding information in any of our counties is a matter of tracking down the right person to ask, which is asking too much of a client in crisis,” Seavey said.
LME membership has been lost due to disillusionment, and recruitment has been unsuccessful he said. “The LME Web site continues to post the names of members who have been long gone in order to maintain the perception of the 'organization,'” he said. “The state has not really experienced mental health reform,” Seavey said. “This has been pointed out to them (state officials) over and over.”
Peggy Manning can be reached at 452-0661, ext. 127, or at email@example.com.
Posted by david at 8:32 AM Permalink
13 June 2006
PLoS Med 2006; 3: e190, e220
The introduction of selective serotonin reuptake inhibitors (SSRIs) does not appear to be associated with an increase in suicide rates, research findings reveal.
Julio Licinio, from the University of California at Los Angeles, USA, and colleagues found a 7% decrease in the rate of suicide since the introduction of fluoxetine in the USA in 1988.
While the reduction in suicide rate cannot to be attributed directly to an increase in the prescription of fluoxetine, the findings do suggest that SSRIs are not "triggering or causing suicides," Licinio, who is currently at the University of Miami School of Medicine, told MedWire News.
He described the findings as "startling," explaining that "if antidepressants were associated with an increase in the risk of suicide, then an increase in the rate of suicide after the introduction of SSRIs would be expected, but the research shows the exact opposite."
In the wake of controversy surrounding SSRI use and suicides, Licinio believes the findings "should assure clinicians that SSRIs do not increase the risk of suicide." He noted, however, patients with clinical depression, particularly those with suicidal thoughts, should be monitored closely.
Licinio and colleagues analyzed suicide rates in the US general population from 1960 to 2002, along with data on the prescription of fluoxetine since its introduction in 1988.
From 1960 to 1988, the suicide rate fluctuated between 12.2 and 13.7 per 100,000 for the entire population. After 1988, the researchers note that suicide rates gradually declined, with the lowest value of 10.4 per 100,000 occurring in 2002.
This decline in suicide rates correlated significantly with an increase in the prescription of fluoxetine, from 2,469,000 in 1988 to 33,320,000 in 2002.
Using mathematical models, Licinio and team predict that had fluoxetine and other SSRIs not been introduced, the number of suicides, based on pre-1988 data, would have increased by about 33,600, which suggests that SSRIs may have saved this number of lives since their introduction.
While the study does not establish a causative association between increasing fluoxetine dispensing and decreased rates of suicide, Licinio et al conclude in the journal Public Library of Science Medicine that "many more lives have been saved than lost since the advent of these [SSRI] drugs."
In a related commentary, Bernhard Baune and Philippa Hay from James Cool University in Australia note that the type of study carried out by Licinio and colleagues does not conclusively prove "whether antidepressants do harm or good at a population level."
They add, however, that the findings are of "public health importance and should stimulate further scientific endeavors."
Posted by david at 6:20 AM Permalink
Monday, June 12, 2006
By BENEDICT CAREY
New York Times
The use of potent antipsychotic drugs to treat children and adolescents for problems like aggression and mood swings increased more than fivefold from 1993 to 2002, researchers reported yesterday.
The researchers, who analyzed data from a national survey of doctors' office visits, found that antipsychotic medications were prescribed to 1,438 per 100,000 children and adolescents in 2002, up from 275 per 100,000 in the two-year period from 1993 to 1995.
The findings augment earlier studies that have documented a sharp rise over the last decade in the prescription of psychiatric drugs for children, including antipsychotics, stimulants like Ritalin and antidepressants, whose sales have slipped only recently. But the new study is the most comprehensive to examine the increase in prescriptions for antipsychotics.
The explosion in the use of drugs, some experts said, can be traced in part to the growing number of children and adolescents whose problems are given psychiatric labels once reserved for adults and to doctors' increasing comfort with a newer generation of drugs for psychosis.
Shrinking access to long-term psychotherapy and hospital care may also play a role, the experts said.
The findings, published yesterday in Archives of General Psychiatry, are likely to inflame a continuing debate about the risks of using psychiatric medication in children. In recent years, antidepressants have been linked to an increase in suicidal thinking or behavior in some minors, and reports have suggested that stimulant drugs like Ritalin may exacerbate underlying heart problems.
Antipsychotic drugs also carry risks: Researchers have found that many of the drugs can cause rapid weight gain and blood lipid changes that increase the risk of diabetes. None of the most commonly prescribed antipsychotics is approved for use in children, although doctors can prescribe any medication that has been approved for use.
Experts said that little was known about the use of antipsychotics in minors: only a handful of small studies have been done in children and adolescents.
"We are using these medications and don't know how they work, if they work, or at what cost," said Dr. John March, a professor of child and adolescent psychiatry at Duke University. "It amounts to a huge experiment with the lives of American kids, and what it tells us is that we've got to do something other than we're doing now" to assess the drugs' overall impact.
But many child psychiatrists say that antipsychotic medication is the best therapy available for children in urgent need of help who do not respond well to other treatments. Without them, they say, many unpredictable, emotionally unstable children would end up institutionalized.
Dr. Mark Olfson, a professor of clinical psychiatry at Columbia University and the lead author of the study, financed in part by the National Institute of Mental Health, said the popularity of antipsychotic drugs might result in part from "the fact that psychiatrists have few other pharmacological options in certain patients."
The study, which looked at visits to pediatricians and other doctors, found that psychiatrists were the most likely to prescribe antipsychotic drugs.
In light of how little these drugs have been studied in children, Dr. Olfson said, "to me the most striking thing was that nearly one in five psychiatric visits for young people included a prescription for antipsychotics."
The Columbia investigators analyzed data from the National Center for Health Statistics survey of office visits, which focuses on doctors in private or group practices. They calculated the number of visits in which an antipsychotic drug was prescribed to people under the age of 21 and collected information on patients' medical histories. The total number of visits that resulted in prescriptions for the drugs increased to 1,224,000 in 2002 from 201,000 1993 to 1995.
The researchers attributed some of the increase to the availability of a new class of drugs for psychosis, called atypical antipsychotics, that were introduced in the early and mid-1990's.
The newer drugs, heavily marketed by their makers, were attractive in part because they appeared less likely than older types of antipsychotics to cause side effects like tardive dyskinesia, a neurological movement disorder similar to Parkinson's disease.
From 2000 to 2002, the new study found, more than 90 percent of the prescriptions analyzed were for the newer medications, and most of the patients were boys, predominantly Caucasian children, who were significantly more likely to see psychiatrists than other ethnic groups.
Some experts also pointed to an increase in the diagnosis of bipolar disorder in children as a contributing factor. In recent years, psychiatrists have begun to diagnose the disorder in extremely agitated, often aggressive children with mood swings short surges of grandiosity or irritation that alternate with periods of despair. These symptoms in children are thought to be related to the classic euphoria and depressions of adult bipolar disorder.
At the same time, several of the atypical antipsychotics, including Risperdal from Janssen and Zyprexa from Eli Lilly, won approval for the treatment of mania in adults.
Some psychiatrists now routinely prescribe atypical antipsychotics "off label" for young people thought to have bipolar disorder, and researchers have begun to study the drugs in children as young as preschool age.
In the new study, about a third of the children who received antipsychotics had behavior disorders, which included attention deficit problems; a third had psychotic symptoms or developmental problems; and another third were suffering from mood disorders. Over all, more than 40 percent of the children were also taking at least one other psychiatric medication.
"We feel the medications are effective in children with bipolar and have some data to show that," said Dr. Melissa DelBello, an associate professor of psychiatry at the University of Cincinnati, who has done several studies of the drugs.
Dr. DelBello said that the field "desperately needs more research" to clarify the effects of the antipsychotic drugs but that many children struggling with bipolar disorder got more symptom relief on these drugs than on others, allowing psychiatrists to cut down on the overall number of medications a child is taking.
Lisa Pedersen of Dallas, the mother of a 17-year-old boy being treated for bipolar disorder, said he was unpredictable, hostile and suicidal before psychiatrists found an effective cocktail of drugs, which includes a daily dose of antipsychotic medication.
"Believe me, I would never choose having him on these meds," Ms. Pedersen said in a telephone interview. "It's not fun watching a child deal with the side effects. But finding the right combination of medicine has made his life worth living."
Yet this process is one of trial and error for many children. Ms. Pedersen said her son had responded badly to the first two antipsychotic drugs he received. And some experts think the way that psychiatric drugs are prescribed is obscuring any understanding of underlying disorders and the optimal treatments.
"If you're going to put children on three or four different drugs, now you've got a potpourri of target symptoms and side effects," said Dr. Julie Magno Zito, an associate professor of pharmacy and medicine at the University of Maryland.
Dr. Zito added, "How do you even know who the kid is anymore?" Read more!
Posted by david at 7:41 AM Permalink
New York Times via the Hendersonville News
By KIRK JOHNSON
New York Times
FLAGSTAFF, Ariz. — Dr. Sara Gibson looked into the television screen and got right down to it.
"What's keeping you alive at this point?" she asked her patient, a middle-aged woman who asked to be identified only as D. D grimaced, looked down, then to the side and finally into Dr. Gibson's face, which filled the screen before her in a tiny clinic three hours east of here in the Arizona desert.
"Nothing," said D, who Dr. Gibson says suffers from bipolar disorder and post-traumatic stress from the sexual abuse she suffered as a child.
It is Wednesday in the hinterlands of rural Arizona, and the psychiatrist is in. Sort of.
Actually, Dr. Gibson was here in Flagstaff in a closet-size office of a nonprofit medical group, with a pale blue sheet behind her as a backdrop and a cup of tea at her side. She is one of a growing number of psychiatrists practicing through the airwaves and wires of telemedicine, as remote doctoring is known.
Psychiatry, especially in rural swaths of the nation that also often have deep social problems like poverty and drug abuse, is emerging as one of the most promising expressions of telemedicine. At least 18 states, up from only a handful a few years ago, now pay for some telemedicine care under their Medicaid programs, and at least eight specifically include psychiatry, according to the National Association of State Medicaid Directors. Six states, including California, require private insurers to reimburse patients for telepsychiatry, according to the National Conference of State Legislatures.
Growing prison populations have a lot to do with the trend. Since reimbursement for prison care is easy and safety issues for doctors are significant, many telemedicine programs, notably an ambitious one in Texas, started there. Now, the falling price of technology is making care available to far-flung rural residents like D.
Dr. Gibson rides a disembodied circuit through this terrain. On Wednesdays, she sees patients in the tiny community of Springerville near the New Mexico border through a firewalled T1 data line, and on Thursdays in St. Johns. Each side of the exchange has its own television-mounted camera, angled so that doctor and patient can maintain the illusion of looking into each other's eyes in real time.
And so, through illusion and delusion, depression, anxiety, paranoia — and here and there a laugh or two — a day in the life of a rural telepsychiatrist and her patients unfolded.
"Is there self-harm going on, too?" Dr. Gibson pressed D, typing notes into the computer and glancing back at the screen. D paused, then quietly said, "Yeah."
Dr. Gibson, 44, was a pioneer in the field. She has been seeing patients only this way for 10 years and is still one of a handful of doctors in the country who practice telepsychiatry exclusively. Her territory is Apache County, which is about the size of Massachusetts and Connecticut combined, but which lacks even a single psychiatrist on the ground for its 69,000 residents despite widespread problems of poverty, drug use, child abuse and a suicide rate that is twice the national average.
The American Psychiatric Association says on its Web site that it supports telemedicine, "to the extent that its use is in the best interest of the patient," and practitioners meet the rules about ethics and confidentiality. But in places like Apache County, where the alternative is no treatment at all, most mental health workers say that every new wire and screen is to be deeply cheered.
"Basically, doctors can do, surprisingly, almost everything," said Don McBeath, the director of telemedicine and rural health at the Texas Tech University Health Sciences Center in Lubbock. "The difference is they can't touch you or smell you."
Dr. Gibson said the lack of smelling and touching, at least when it comes to psychiatry, has proved to be a good thing. Being physically in the presence of another human being, she said, can be overwhelming, with an avalanche of sensory data that can distract patient and doctor alike without either being aware of it.
"Initially we all said, 'Well, of course it would be better to be there in person,' " she said. "But some people with trauma, or who have been abused, are actually more comfortable. I'm less intimidating at a distance."
Some of the doctor's patients, who agreed to allow a reporter and photographer to observe their therapy sessions over two recent days — one day in Flagstaff with Dr. Gibson, the second day in a field clinic in St. Johns, population 3,000 — said they were in fact perfectly happy with the doctor's being hundreds of miles away, though some were quick to add that no offense was intended.
"Some people don't want to have to deal with a real person," said one patient, a 63-year-old woman who has dementia and bipolar disorder.
One thing Dr. Gibson has learned over the years is that she should not wear stripes or zigzag patterns, which can look strange on television, especially to already disturbed people. For patients with paranoia, she regularly pans the camera around her little room to prove that no one else is lurking and listening. (A white-noise machine purrs outside Dr. Gibson's office door, muting the exchanges within, and no session is ever recorded.)
She worries, sometimes, about the children she sees, almost all of whom immediately and enthusiastically embrace the idea of a talking to the nice, chatty woman on the television. "Do they understand that the TV doesn't always talk to them?" Dr. Gibson said.
Another patient, Mike Kueneman, who allowed his full name to be used, has seen Dr. Gibson for about five years, through the periods with the voices in his head and what he calls the "psychotic episode" that landed him in jail this year on burglary charges. Mr. Kueneman said he felt more comfortable with Dr. Gibson, even though they have never met in person, than he does with most of the people he knows.
Like most of Dr. Gibson's patients, he pays little or nothing to see her. State programs for low-income and mentally ill people pay for the $120 psychiatric evaluations and $40 follow-up visits — and for the medicines she prescribes, which can cost thousands of dollars.
"It's hard for me to trust any other doctor," said Mr. Kueneman, who attended a telesession in the St. Johns clinic in leg shackles and handcuffs, accompanied by an Apache County sheriff's deputy.
Some things did not happen as expected. Dr. Gibson predicted, for example, that at least one patient would incorporate the teleconferencing technology into his or her delusions and come to believe that telemedicine could be used to read people's thoughts or get inside their heads.
To the contrary, in matters of the psyche — two people in two rooms looking at each other across a cool electronic medium — it is still all about human connection.
"I just feel like she's here," said a 24-year-old mother of three who asked to be referred to as C. C was struggling with depression, anxiety and fantasies of suicide. "I sometimes forget we're not in the same room."
Dr. Gibson spoke up from her room in Flagstaff: "That's funny, I would say that I feel the same way."
Dr. Gibson and C have known each other across the telewaves since C became a single mother on her own at age 17.
The emotions ran deep as they spoke and C described the dark thoughts that sometimes come at night. Gripped by insomnia, convinced that someone else is in the trailer she lives in, her mind races, she said, and the fantasy rolls out of how she might take her youngest child with her and disappear, driving off into the night.
"I don't want you killing yourself," Dr. Gibson said with a matter-of-fact tone. "So that means talking."
Apache County had a genuine, in-the-flesh psychiatrist once, Dr. Julia Martin, who practiced there for about 10 years until her retirement in 1996.
Dr. Martin was trained as a pediatrician and went back to school for psychiatry in her 50's. For more than a decade, she was it, the county's solo psychiatrist and also the only one serving the nearby Fort Apache Indian Reservation.
"You did get to know your patients pretty well — sometimes better than you'd like," Dr. Martin, 74, said in a telephone interview from her home in a remote corner of the county. Sometimes people would show up in the middle of the night, she said, desperate to see her. Other times, they delivered brownies.
What Dr. Gibson's patients imagine of her life and what she is like when she is not on camera is unknown. She sometimes mentions her children to them, and her passions for music and singing. She speculated that telemedicine has probably in some ways amplified and enlarged her image in the minds of some patients — that if she is on television she must be really important, larger than life.
She has been to Apache County once, for a "meet the psychiatrist" event in St. Johns years ago. Many of the patients who showed up remarked, she said, about how much shorter she was than they had expected.
Posted by david at 6:49 AM Permalink
June 12, 2006
By N. R. KLEINFIELD
Dr. John Newcomer is a psychiatrist who generally treats people with severe ailments of the mind and spirit. But before his patients sit down, before he hears about their clammy paranoia or renegade voices, Dr. Newcomer wants to know about their waist size.
He steers them to a scale to learn their weight. He orders a blood sugar test. If big numbers come up, he begins a conversation about Type 2 diabetes, a disease associated with obesity that is appearing with alarming frequency among the mentally ill.
"Uncontrolled diabetes can ruin a person's life as much as uncontrolled schizophrenia," said Dr. Newcomer, a professor of psychiatry at Washington University School of Medicine in St. Louis.
In fact, among the mentally ill, roughly one in every five appear to develop diabetes - about double the rate of the general population. This is a little-recognized surge, but one that is jolting mental health professionals into rethinking how they care for an often neglected population.
For decades, psychiatrists have worried primarily about patients' mental states, making sure they did no harm to themselves or others because of unrelenting voices or a smothering depression.
Far more of the mentally ill, however, die today from diabetes and complications like heart disease than from suicide. Given that mental health specialists are often the only doctors a mentally ill diabetic ever sees, some have begun to debate the customary limits of psychiatric practice, deciding to pay much more attention to physical ailments.
In particular, psychiatrists must confront the fact that diabetes, marked by dangerously high blood sugar, is often aggravated, if not precipitated, by some of the very medicines they prescribe: antipsychotic pills that have been linked to swift weight gain and the illness itself.
"It's bad enough that these people have mental illness, and then they take treatments and they bring on diabetes," said Dr. Jeffrey Lieberman, chairman of the psychiatry department at the Columbia University College of Physicians and Surgeons.
Treating the diabetic mentally ill can be formidable. The regimen of blood testing, dieting and exercise that controls Type 2 diabetes is often beyond the attentions of the mentally ill. For patients, the task of taming two debilitating illnesses can haunt their lives. Michael Schiraldi, 44, a Manhattan man who has both schizoaffective disease and diabetes, said his mental illness, now stabilized, was the lesser of his concerns.
"I can't really control the diabetes," he said. "I might die from it."
The doctors who regard diabetes as a galloping threat to the mentally ill acknowledge that many in their profession still dispute, or ignore, its consequences. Dr. Newcomer said colleagues often whine about how hard it is to weigh patients. " 'Oh', they'll say, 'there's no scale' or 'It's in a closet someplace,' " he said.
Yet he says he hopes other doctors will eventually share his perspective as diabetes expands among the mentally ill and deepens into an even graver problem.
Betrayals of Body and Mind
Carole Ernst doesn't know how she got diabetes.
Genes? Her mother had it.
Lifestyle? She eats more than she should, exercises less than advisable.
Or was it the pills that shushed the TV?
The TV no longer speaks to her. She stared levelly at the set in her messy room. It was blessedly quiet.
She is 53 and has battled mental illness since childhood. The pills for her illness, diagnosed as schizoaffective disorder, have helped. But she feels they have also made her fat around her abdomen, the kind of fat that can lead to diabetes.
So even though Ms. Ernst feels better mentally - she no longer imagines everyone despises her - diabetes has been a crippling insult to her troubled psyche. In the late hours, alone in her room on the Lower East Side of Manhattan, trapped in the undertow of two potent diseases, she runs on empty.
"Some nights, the only thing I can do is read my Bible," she said. "I look in there to find answers. They're hard to find."
Diabetes on top of mental illness asks a lot of a person, and of society. Mental illness is itself a money sponge, an expense borne largely by tax dollars. But that cost may be dwarfed by the bill to manage the heart attacks and amputations that diabetes bestows.
With numerous mental institutions emptied, patients often live in lightly supervised settings. Many occupy adult homes that struggle, for good reasons and bad, at providing basic services and are poorly equipped to treat diabetes. Others live on their own, sometimes in boxes beneath bridges or crumpled in doorways.
Imagine taking on diabetes if you live alone and find living itself to be a handful.
"I try not to drink sugared sodas, but sometimes I forget," Ms. Ernst said. "I'll buy candy - Mary Janes or banana cookies. I know I'm not fooling anybody - it's my arms and legs they're going to cut off - but sometimes I get the craving for something sweet."
She sat at a round table in her room, a cool evening of early spring, cradling a stuffed bunny. She flicked a small smile. "I'm sorry it's not neater," she said, looking around. "I'm trying."
Ms. Ernst embodies the difficulty of confronting the two diseases with all their complexities. She takes clozapine for her mind because she can't manage without it. She has diabetes and can't defeat her weight.
"Disgusting, that clozapine," she said. "Makes you eat everything under the sun." She takes a lineup of other drugs, too, not all positive for her weight. She had hit 250, fought her way to 198, and is now at 221.
She lives at Gouverneur Court, a residence run by a nonprofit organization, where about 15 of the 66 mentally ill residents have diabetes. "Some say they don't have it, but they do," said Abby Stuthers, the nurse who works there. "Or they say they have a little diabetes."
Ms. Ernst freely recounts her callused life. Her marriage exploded. Once she was smacked in the face with a glass ashtray. She opened her mouth - every tooth was missing.
Now diabetes. Her blood sugar has been O.K., but her vision has worsened. And she is inconsistent, prey to the fury of her demons.
Susanne Rendeiro, a family nurse practitioner who serves as her primary care physician, said Ms. Ernst misses half her appointments. Recently, in reviewing her drugs, Ms. Rendeiro asked about her blood pressure pills. Puzzled, Ms. Ernst said she was not on blood pressure pills.
Mrs. Rendeiro said she had supposedly been taking them for two years.
"I want to be the best I can be," Ms. Ernst said. "Nobody changes overnight."
Treatment and Cruel Ironies
There was always a lot else wrong with the mentally ill - heart problems and cancer and H.I.V., as well as diabetes. But for psychiatrists and clinicians it was enough to worry about mental needs that beggared the imagination.
The spread of diabetes, however, is making the physical conditions impossible to ignore. "Psychiatrists are literally watching patients balloon up before their eyes," said Dr. Gail Daumit, an assistant professor of medicine at Johns Hopkins Medical Institutions.
This has been especially true since the advent of so-called atypical antipsychotic drugs in the early 1990's. Studies indicate that these drugs can alter glucose metabolism and stimulate weight gain, particularly in people predisposed to diabetes.
"Sort of a cruel irony in this," said Dr. Lieberman of Columbia, "is that all of the drugs do it to some degree, but the ones that have the most effect cause the most weight gain and metabolic side effects. There's increasing discomfort that these are driving up deaths and lowering quality of life."
Some cases have been striking: a patient packing on 50 pounds in mere months, for example. Diabetes arrived as quickly, and sometimes subsided if the drugs were halted. In certain instances, there was no weight gain, but still diabetes came, often in patients who were already heavy. Studies have indicated that dozens of these patients died from diabetes-related complications.
The Food and Drug Administration requires atypical antipsychotics to bear warning labels about diabetes risk, though drug makers say patients taking them who develop diabetes were destined to get it anyway.
Robin Stigliano's psychiatrist has her taking Haldol by injection as well as one of the drugs most closely associated with weight gain, Zyprexa. They have helped her schizophrenia, but Ms. Stigliano, 37, who lives in a Brooklyn adult home, has seen her weight soar to 241 pounds from 150. And when she gets her Haldol infusion every three weeks, all she wants to do is sleep. "It's my favorite activity," she said.
Without the drugs, psychiatrists believe, many high-functioning patients would find themselves in institutions or jail. "These drugs are enormously beneficial," said Dr. P. Murali Doraiswamy, head of biological psychiatry at Duke University. "But they have an Achilles heel."
A few years ago, Dr. Doraiswamy reported a case of a mentally ill person who got diabetes and was prescribed insulin. The impact of having two serious conditions overwhelmed him. He wound up trying to kill himself by insulin overdose.
Some researchers think it is possible the rash of diabetes stems in part from mental illness itself. Studies associate the onset of diabetes with depression. The mentally ill are also at high risk because they tend to eat poorly, get little exercise and have limited access to health care.
In a 2003 survey, the city's health department found that about 17 percent of adults who reported symptoms of a mental illness, or 52,000, have diagnosed diabetes. Elsewhere, rates are as great or greater. Even these estimates may be low, experts said, because the mentally ill see doctors sporadically and their illnesses may be underdiagnosed.
The rates of diabetes and obesity are nudging Dr. Doraiswamy and others in his field - in modest ways thus far - toward prevention, toward screening people for diabetes before choosing drugs and connecting better with primary care doctors.
"This wouldn't be a big problem if most mentally ill patients had a primary care provider, but they don't," said Dr. Newcomer at Washington University. "And it's never been part of the game plan for the psychiatrist to write the prescription for your blood pressure medicine or your diabetes medicine."
He feels change is imperative. "The days when I don't do windows can't go on," he said.
Dr. Kenneth Duckworth, medical director for the National Alliance on Mental Illness, agreed. "I think the field has been passive," he said. "We viewed it that we do symptoms and you run your life."
Stimulating change is not easy. Psychiatrists have a problem simply getting patients to stay on their drugs. Resources are inadequate.
"Psychiatry is historically a couch and the chair," Dr. Duckworth said. "How do you get movement into the equation?"
He said that he weighed his patients, checked sugars. But few psychiatrists are set up to do this. Treating diabetes, they say, was not what they were trained to do. And where, they ask, do they find time in 15-minute appointments?
"Most psychiatrists barely look at their patients," said Dr. Donna Ames Wirshing, a staff psychiatrist at the West Los Angeles Veterans Administration Medical Center. She recently asked 30 how many weighed their patients; 3 hands went up.
Dr. Wirshing and her husband, Dr. William Wirshing, are experimenting with the use of nutrition and exercise coaches for mentally ill patients.
Couches could be replaced with exercise bikes. Or, as Dr. David Hellerstein, associate professor of clinical psychiatry at Columbia's College of Physicians and Surgeons, noted, "Instead of having the patient lie down and you say, 'So tell me why you fight with your brother,' you could say to the patient, 'Let's take a walk around the block while you tell me about why you fight with your brother.' "
For the most part, however, psychiatrists confront the knotty questions without ready answers.
If some 10 percent of schizophrenics kill themselves, and clozapine is the only antipsychotic medication demonstrated to significantly reduce suicide, but it has grave side effects, like its association with diabetes, is it miracle or monster? Or both?
"When I chat with patients, about clozapine, I say, 'This may give you your mind back, but it may hurt your body,' " Dr. Duckworth said. "I think of it as psychiatric chemotherapy. Your hair won't fall out, but you may get diabetes."
How do patients respond? "Some say, 'If this will give me my mind, I'll take anything,' " he said. "Some say, 'There's nothing wrong with me, why are we even having this conversation?' About 60 percent of schizophrenics don't recognize that they have it. There are very few easy answers in my line of work."
Housing the Ill and Diabetic
Surf Manor squats on the tip of Coney Island, one of the dozens of profit-making adult homes in the city where thousands of the mentally ill live. Residents complain about the food. Activities are light on exertion. The week's offerings are taped to the wall: dominoes, blackjack, manicures, jewelry class.
So the men and women eat, sleep, smoke, watch TV, sleep - then do it all over again. Unsurprisingly, those who live there say, dozens of the 200 residents struggle with diabetes.
These often-troubled homes where so many of the mentally ill are housed, frequently grumbling about inadequate attention to their needs and their dignity, can be hideously difficult places for someone at high risk for diabetes. And that is basically everyone who lives there.
Leslie Hinden, a chatty man of 51, sat listlessly in the lounge, near the junk food dispensers. He'd be buying sweets but was broke from binging.
He has had schizoaffective disease - characterized by symptoms of schizophrenia and depression - for most of his life. Sometimes he hears Indian war whoops in his head. About 17 years ago, he picked up diabetes, too.
His blood sugar was 289 that morning, he said. A normal fasting blood sugar reading is below 126 milligrams per deciliter.
"I cheated," he said. "Last night I ate two eclairs. Had a Coke. A lot of times I don't cheat and it goes up to 300. I don't know what to do."
Why the binge last night?
"I don't know," he said. "I felt scared."
A recent State Department of Health sampling of 19 homes found that nearly a quarter of residents had diabetes. The homes say they do what they can. Some have diabetes sections in the dining halls, where occupants get a sugar-free dessert.
"I'm not a doctor, but we're very helpful," said Mordechai Deutscher, the case manager at Surf Manor, who said he did not think the home had many diabetics. "The people here are doing very well."
Even mental health advocates have not given diabetes much attention. The Commission on Quality of Care and Advocacy for Persons with Disabilities, a state watchdog agency, said it has never examined diabetes prevalence or care.
At Surf Manor, Mr. Hinden, like the other diabetic residents, cannot have a blood sugar meter or give himself insulin. Needles are considered perilous. He depends on the staff. But no one prescribes motivation or understanding. And where diabetes requires vigilant self-management, illnesses like schizophrenia often mean memory problems and lack of drive.
"I'll be honest with you, I don't understand diabetes," Mr. Hinden said. "I don't understand it at all."
Joseph Franklin, 47, sat down, all 300-plus pounds of him. He said he has been taking diabetes drugs for seven years. "It's just in case," he said.
He said he was bipolar: "I couldn't see people with shoes on. If I saw someone with shoes on, it could do something to my forehead."
He spread out some greeting cards he had made. He leaned close. "Listen, I don't want everyone to hear this," he said, "but it's very possible that, unless the doctor made a mistake, I do have diabetes."
A stoic man of great girth named Lee Symons, 57, nodded. He had it, too. He hears guitars and banjos thrumming in his head.
Was he trying to diet?
"No one told me to," he murmured.
What about the diabetes?
"As long as it doesn't hurt, I don't mind it," he said. "It's just diabetes."
Posted by david at 6:38 AM Permalink
Saturday, June 10, 2006
Letter to the Editor
by Hugh Moon
published June 10, 2006 12:15 am
I continue to read about the crisis in the mental health services. I served as Area Director of Mental Health, Developmental Disabilities and Substance Abuse services during the time N.C. was considered to have the model for the country.
I believe our state is on a wrong path for these needed services. Private providers are well-equipped to provide their individual services and do a great job; however, these health issues need a system of services if they are to meet the needs of citizens.A collaborative community response is essential. They must include education of the public, early intervention, training for providers, coordination with the other systems of the community, consultation for those who come into contact with those needing services (i.e. hospitals, local police, sheriffs, vocational rehabilitation, schools and others). A system of services as a public service and contracts with private providers can meet the needs of citizens. A private provider-only system will not work. Personnel, financial management, training, supervision, monitoring and other activities must be in place in a system if these services are to be available, usable and of the quality necessary.
Sylva Read more!
Posted by david at 6:10 AM Permalink
Online screening tool:http://www.militarymentalhealth.org/
By DAVID CRARY : AP National Writer_May 30, 2006 : 2:04 pm ET
NEW YORK -- Concerned by rising stress levels in the ranks, the Defense Department has quietly started an online self-screening program in hopes that anonymity will help some service members and their spouses overcome reluctance to confront possible mental-health problems.
"It's an excellent tool -- available 24/7 so you can do it at night when nobody's watching," said Deborah Manning, who coordinates Army substance-abuse programs at Fort Benning, Ga. "The anonymity can make a big difference to a soldier who's been trained to think, 'I'm macho. I can handle this.'"
Air Force Col. Joyce Adkins, a psychologist at the Pentagon's Health Affairs office, said several thousand people have used the Mental Health Self-Assessment Program since it went online four months ago. The program assesses answers to questions about recent behavior and mood swings. If the responses indicate possible trouble, it suggests options for seeking help.
The effort is among the latest of numerous military initiatives undertaken to cope with stress, depression and other mental-health problems that have proliferated since the wars in Iraq and Afghanistan led to tougher overseas deployment schedules.
The Army, for example, has assigned combat stress teams to units in Iraq following an increase in suicides among soldiers there. Service members returning from Iraq have been required to complete a survey used to decide who might need further psychological help; a recent Pentagon study found that a third of them received counseling.
The new online program is aimed at members of all military branches, whether or not they have been in war zones, and also at their families.
"The stress has been astronomical in the last couple of years," Manning said. "And it may be more so for family members left behind -- wondering, worrying, sitting there watching as CNN takes you there (Iraq) live."
Tom Angelo, a sonar technician who helps run substance abuse programs at the Navy's submarine base in Bangor, Wash., said the self-screening program provides an opportunity for a service member's spouse to seek help in a private, low-key manner.
"There's still some underlying stigma that we have to overcome -- a lot of people who don't want to mess with their husband's or wife's career," he said. "This online process definitely opens up more of an opportunity."
Stress unquestionably has been increasing at his base, Angelo said.
"Ships and subs deploy more often -- people are asked to do more with less," he said. "There's a lot more anxiety and depression, especially with the younger guys, the newlyweds, guys with newborn babies. Half the time you never know where you're going or when you'll be back."
The online program, developed by a nonprofit group called Screening for Mental Health, is divided into subsections addressing depression, post-traumatic stress, anxiety, bipolar disorder and alcohol abuse. It is free and confidential; participants are asked about deployment records and military status but not for any details that would identify them.
"It's a first step for people wondering, 'Do I need help?'" said Joyce Raezer of the National Military Family Association.
Still, while Raezer commended the military for trying to expand support programs for family members, she questioned whether resources are sufficient, noting a nationwide shortage of child psychiatrists as an example.
Stephen Robinson, legislative director for the Vietnam Veterans of America Foundation, is more critical. He said questionnaires, whether completed online or at group screening sessions, are inadequate substitutes for individual face-to-face encounters with mental health professionals.
The online program "is well-intentioned but not well thought-out," he said. "I doubt it will produce any measurable help for soldiers."
Adkins, however, said it is impossible to provide face-to-face screening and counseling at every moment that a service member or relative might need it.
The online option, she said, "is always available. You don't have to go anywhere. You don't have to have child care or change your clothes." Even some soldiers in Iraq have used the online screening, she added.
The Pentagon is committed to the program at least through the next fiscal year and plans to introduce a Spanish version, Adkins said.
"Everybody agrees there's more stress out there," she said. "The best thing we can do is acknowledge the stress and find ways to alleviate it."
Posted by david at 5:19 AM Permalink
Friday, June 09, 2006
People can read the panel's report and submit comments athttp://www.citizenshealthcare.gov
Core benefits are urged for all Americans by 2012 even if taxes have to be raised. Congress and the president will be required to respond.
By Ricardo Alonso-Zaldivar, Times Staff Writer
June 9, 2006
WASHINGTON — The government should guarantee a core set of health benefits for all Americans by 2012 even if it means raising taxes, a nonpartisan advisory panel created by Congress has recommended.
Normally, such a recommendation might not get even a polite acknowledgment in an election-year climate in which tax increases are taboo. But the legislation that created the 15-member Citizens' Health Care Working Group requires the president to comment and five congressional committees to hold hearings once the panel's report is finalized.
"I think it could work as a conversation starter," said health economist Marilyn Moon of the American Institutes for Research. "We are getting close to having a conversation on what needs to be done about healthcare, in part because people who have health security at the moment are less secure than they would like to be. People who have employer coverage are seeing it undermined."
National polls as recently as 2005 have shown solid backing for guaranteed health insurance, even if it would mean raising taxes somewhat. Support decreases, however, if it would involve substantial tax increases or premium hikes.
The panel's report follows Massachusetts' decision to cover all its uninsured residents by July 2007 through a mix of employer plans, government programs and a requirement that uninsured people purchase coverage if they can afford to do so.
The recommendations of the national panel, which are to be finalized after a public comment period that ends Sept. 1, call for immediate and long-range changes.
In the near term, all Americans should have protection against catastrophic healthcare expenses, either through a government program or a private insurance plan, the panel recommended.
It also called for increased support for safety-net healthcare providers, such as community health centers, and for a concerted effort to improve quality of care and information for patients. And it suggested increasing access to hospice care for patients nearing death.
The panel said that in the long term — by 2012 — all Americans should have coverage for a core package of healthcare services, including preventive care, doctor visits, hospitalization and prescription drugs.
The recommendations "call for actions that will require new revenues to provide some healthcare security for Americans who are now at great risk," said the panel's interim report. It listed income taxes, payroll taxes, business taxes, sales taxes and taxes on alcohol and tobacco as possible sources of revenue.
"We have a long-run vision that is ambitious, but we have some interim solutions that are very practical and consistent with today's budgets," said panel member Richard G. Frank, a health economist at Harvard Medical School.
Members of the panel include doctors, nurses, a hospital administrator, advocates for patients and business representatives. Secretary of Health and Human Services Michael Leavitt is also a member but took no position on the recommendations.
"After 60 years of the same approach to healthcare reform, we wanted to try something different," said Sen. Ron Wyden (D-Ore.), a sponsor of the legislation that created the panel. "In the past, influential people in Washington have made recommendations to the American people. Now, the hope is to see if a citizen-driven process can provide a general roadmap."
Sen. Orrin G. Hatch (R-Utah), a coauthor of the legislation, said in a statement that the commission's report was a "positive first step."
Neither he nor Wyden has said whether they will support the panel's specific recommendations.
Health policy analyst Greg Scandlen criticized the recommendations.
"They go in the wrong direction, it's all top-down, command-and-control stuff," he said.
Scandlen advocates widespread adoption of health savings accounts, which allow consumers to pay the costs of routine care while using their insurance for serious medical problems.
Posted by david at 7:10 AM Permalink
Thursday, June 08, 2006
WASHINGTON, June 8 /PRNewswire/ -- Addressing a crowd of mental health advocates, consumers, policy makers and community leaders at the National Mental Health Association's 2006 Annual Meeting, Building the Movement, U.S. Representative Patrick Kennedy (D-R.I.) called on Congress today to end discrimination of individuals with mental illnesses by passing meaningful mental health reform legislation. The address was part of an 'Advocacy Day' Plenary, also featuring former First Lady Rosalynn Carter, to prepare mental health advocates from across the country for afternoon meetings with their Congressional representatives.
People with mental illnesses are, "suffering the same types of injustices that civil rights [workers] have fought against," said Rep. Kennedy, a long- time champion of mental health issues who has courageously spoken out about his own experience with mental illness. "I appreciate that you all are fighting the good fight-for everyone."
Kennedy urged audience members to encourage their representatives to enact mental health insurance parity legislation, which would require insurance providers to cover mental and physical healthcare equally. "There is no reason why Members of Congress have parity and the rest of the country does not," Kennedy said. Kennedy is a co-sponsor of a companion bill, the Ramstad Bill, to the Senate's parity bill, where the advancement of parity legislation has been particularly difficult.
Citing national statistics, including the fact that suicide occurs at twice the rate of homicide, Rep. Kennedy lamented the lack of attention to mental health issues in politics and the mainstream press and urged the audience to continue their efforts to make mental health a national priority in 2006.
NMHA's 2006 Annual Meeting, Building the Movement, held from June 7-10 in Washington, D.C., brings together nearly 500 mental health advocates, consumers and policymakers to share knowledge, strengthen the nation's mental health movement and to ultimately improve the wellness of all Americans.
The National Mental Health Association is the country's oldest and largest nonprofit organization addressing all aspects of mental health and mental illness. With more than 340 affiliates nationwide, NMHA works to improve the mental health of all Americans through advocacy, education, research and service.
CONTACT: Jason Halal of National Mental Health Association,+1-703-797-1943, firstname.lastname@example.org
Posted by david at 6:46 AM Permalink
Wednesday, June 07, 2006
Some cases of abuse, road rage likely stem from condition, researchers say
To you, that angry, horn-blasting tailgater is suffering from road rage. But doctors have another name for it -- intermittent explosive disorder -- and a new study suggests it is far more common than they realized, affecting up to 16 million Americans.
"People think it's bad behavior and that you just need an attitude adjustment, but what they don't know ... is that there's a biology and cognitive science to this," said Dr. Emil Coccaro, chairman of psychiatry at the University of Chicago's medical school.
Road rage, temper outbursts that involve throwing or breaking objects and spousal abuse can sometimes be attributed to the disorder, though not everyone who does those things is afflicted.
By definition, intermittent explosive disorder involves multiple outbursts that are way out of proportion to the situation. These outbursts often include threats or aggressive actions and property damage. The disorder typically first appears in adolescence; in the study, the average age of onset was 14.
The study was based on a national face-to-face survey of 9,282 U.S. adults who answered diagnostic questionnaires in 2001-03. It was funded by the National Institute of Mental Health.
About 5 percent to 7 percent of the nationally representative sample had had the disorder, which would equal up to 16 million Americans. That is higher than better-known mental illnesses such as schizophrenia and bipolar disorder, Coccaro said.
The average number of lifetime attacks per person was 43, resulting in $1,359 in property damage per person. About 4 percent had suffered recent attacks.
The findings were released Monday in the June issue of the Archives of General Psychiatry.
The findings show the little-studied disorder is much more common than previously thought, said lead author Ronald Kessler, a health care policy professor at Harvard Medical School.
"It is news to a lot of people even who are specialists in mental health services that such a large proportion of the population has these clinically significant anger attacks," Kessler said.
Four a couple of decades, intermittent explosive disorder has been included in the manual psychiatrists use to diagnose mental illness, though with slightly different names and criteria. That has contributed to misunderstanding and under appreciation of the disorder, said Coccaro, a study co-author.
Coccaro said the disorder involves inadequate production or functioning of serotonin, a mood-regulating and behavior-inhibiting brain chemical. Treatment with antidepressants, including those that target serotonin receptors in the brain, is often helpful, along with behavior therapy akin to anger management, Coccaro said.
Most sufferers in the study had other emotional disorders or drug or alcohol problems and had gotten treatment for them, but only 28 percent had ever received treatment for anger.
"This is a well-designed, large-scale, face-to-face study with interesting and useful results," said Dr. David Fassler, a psychiatry professor at the University of Vermont. "The findings also confirm that for most people, the difficulties associated with the disorder begin during childhood or adolescence, and they often have a profound and ongoing impact on the person's life."
Jennifer Hartstein, a psychologist at Montefiore Medical Center in New York, said she had just diagnosed the disorder in a 16-year-old boy.
"In most situations, he is relatively affable, calm and very responsible," she said. But in stressful situations at home, he "explodes and tears apart his room, throws things at other people" to the point that his parents have called the police.
Hartstein said the study is important because many people are not aware of the disorder.
Disorder and Road Rage
People with rage disorder often misinterpret another person's harmless action as a personal threat to them and respond by slapping, hitting or threatening another person, by breaking things, by punching holes in walls or by trying to run somebody down with their car, said Dr. Emil Coccaro, chairman of psychiatry at the University of Chicago's medical school.
Two things generally set these people off, he said: perceived threats and frustrating situations. So the road rage person may explode for both reasons; he feels threatened by being cut off in traffic and frustrated because traffic congestion keeps him from getting to where he wants to go quickly.
While many people under similar conditions may honk their horn or yell, that's more like a temper tantrum than the potentially deadly kind of reaction of someone with rage disorder, Coccaro said.
The majority of men who engage in spousal abuse are sociopathic and could control their behavior, but about a third may suffer from IED and impulsively strike out, he said.
Anger attacks can be reduced with drug therapy to raise the threshold at which people explode, or with cognitive behavioral intervention that teaches a person how to relax when they feel tense and how to recognize that another person is not trying to hurt them, Coccaro said.
"The simplest coping skill is to get out of the encounter," he said. "If you feel you're going to explode you just walk away, take a time out."
Posted by david at 7:44 AM Permalink
Mental health needs fall on other agencies
By Cheryl Welch
Southeastern Center for Mental Health is disintegrating. Once the primary source of mental health services for about 15,000 patients and with 225 clinical staffers, the organization is on the tail end of its state-mandated transformation to a referral and resource center.
So far, the South 17th Street center is down to 4,000 patients served by 132 staffers. According to the Mental Health Reform Act passed in 2001, it is supposed to refer all of its patients elsewhere by 2007.
Among the act's aims are shifting patients from state hospitals to local communities and giving patients more choices in how they're treated. Under the reform, Southeastern must shift the care of these patients to counselors, psychologists and psychiatrists in private practice.
Southeastern and the 29 centers like it in the state have hit a road block - a lack of psychiatrists to take their remaining patients, many of whom have severe and persistent mental illnesses and most of whom are poor, uninsured or on Medicaid. About half of the center's clients need psychiatrists, who can prescribe medications.
"Psychiatrists would prefer not to see our clients," said Art Costantini, Southeastern's director, noting that of the 25 psychiatrists in the Wilmington area, only three are taking the center's patients and then usually with restrictions on the type of patient sent to them. "There are enough people with insurance and deep pockets that they don't have to see our kinds of clients."
There is just no incentive, Costantini noted, explaining Southeastern spends $220,000 a year in salary and benefits for one of its psychiatrists and each is only able to generate $60,000 to $75,000 by seeing these patients.
Pender and Brunswick have a different problem. The two rural counties have a total of three psychiatrists, two of whom are contracted by Southeastern.
Another stumbling block the center has encountered is that about 10 to 20 percent of the patients referred to private practices have since fallen off the radar screen. Some later show up in crisis situations, taxing community resources at homeless shelters, clinics, hospital emergency rooms and jails.
"There are people who fall through the cracks, there's no question of that," Costantini said. "It's two steps forward, then one step back."
The situation has not been ideal for the patients being sloughed off to other providers. They were used to the staff and going to Southeastern for one-stop shopping.
"That's scary; scary not just for me, but all of us," noted Karen Tingler, 52, who suffers from severe depression and post-traumatic-stress disorder.
Tingler, a former finance administrator at a nonprofit agency, became a patient at Southeastern in January after a landslide of events in her life. Her son was shot to death when three men robbed the Wilson, N.C., Pizza Hut where he worked. Just weeks later her father, and then her uncle, passed away and her divorce was finalized. She spiraled into depression, moved to Wilmington to be near her daughter, and sought help.
"It was a struggle just to get out of bed," Tingler recalled. "They've helped me. They care. You're finally healing and then you have to start all over and open up all the wounds again? It's just too hard."
Tingler, who has a part-time job and is approaching the first anniversary of her son's death, said she has one more appointment at Southeastern with her psychologist, who will be leaving soon. She has been told her psychiatrist will remain for a little while.
Costantini said he can't afford to let all the psychiatrists go just yet because there's nowhere to send the patients. "We can't turn them out in the community without a provider," he said.
But the patients are already there, and community agencies are coping.
NEW HANOVER REGIONAL MEDICAL CENTER had double the number of emergency psychiatric visits from 2003 to 2005, clogging its emergency rooms. It has responded by placing psychiatric nurses in the emergency rooms to identify such patients and help streamline them into its Oaks Behavioral Health Hospital and accompanying outpatient programs. The hospital is also on track to construct a larger Oaks to open as early as fall 2007.
TILESTON OUTREACH HEALTH CLINIC also has caught its fair share of mental health patients at its free clinic. Many are homeless, but most are among the working poor, noted its executive director Trish Doyle. To send them back to Southeastern is becoming less of an option, and the clinic is working to put a more formal mental health clinic in place to address the need.
LAW ENFORCEMENT agencies also get take up some of the slack when these patients drop off the grid, stop taking their medications and get into trouble. New Hanover County's jail administrator, Capt. L.A. Ruefle, said many are arrested for minor offenses such as trespassing, damage to property or larceny. They arrive at the jail and are given their medications while they're there. When released, some stop taking the medication and "end up back in jail" in what seems to her like a never-ending cycle. Ruefle said that while it seems to her that the jail has seen more of these cases, the data doesn't indicate that, and Wilmington Police Department data doesn't record such things.
"It's a huge crisis," said Sen. Julia Boseman, D-New Hanover.
Boseman is one of the co-sponsors of several bills in the N.C. Senate that could put $105 million into addressing some of these mental health issues statewide.
"We need to address the problem before it gets worse," she said, adding she's looking forward to seeing what happens as the budget proposal works its way through the N.C. House.
Columnist Si Cantwell contributed to this report.
Posted by david at 7:39 AM Permalink
June 7, 2006
Making his first public appearance since his latest stint in addiction treatment, Rep. Patrick Kennedy (D-R.I) said his struggle with the disease and co-occurring mental illness is ongoing, the Boston Globe reported June 5.
Kennedy, who checked into the Mayo Clinic after a late-night car crash in Washington in May that occurred under the influence of prescription drugs, told a Brown University audience in Providence, "On June 2, I concluded my treatment at the Mayo Clinic. I recognize that 'concluded' is not a word that I will ever be able to use when it comes to my aftercare. I have struggled with addiction and dependency for much of my life, and I remember a friend who successfully battled cancer once saying you can never say for sure that you're 100-percent cured from cancer until you die at age 95 of something else. This is true for addiction, as well."
Kennedy, 38, used the appearance at a behavioral-health conference to call for increased support for mental-health care and less stigmatization of people with mental illness. Kennedy has been in and out of treatment for addiction and mental-health problems since his teens, including two stints in the Mayo Clinic this year.
Kennedy said he had received a great deal of support since the latest incident. "Hundreds shared their personal experience with this disease," he said.
A group of Kennedy supporters that included the heads of the Rhode Island medical and psychiatric societies paid for a full-page ad in the Providence Journal expressing support for the congressman. "No elected official in the country has been more outspoken on behalf of reducing stigma, gaining parity for mental illness, increasing access to mental-health treatment, and furthering the science of the brain," the ad said.
However, the spokesman for the Rhode Island Republican Party said that Kennedy has shown that he can't do his job representing the state in Washington and should resign. Read more!
Posted by david at 7:22 AM Permalink