Researchers Find Almost Half Of Kids With ADHD Not Being Treated - Washing University

In contrast to claims that children are being overmedicated for attention-deficit/hyperactivity disorder (ADHD), a team of researchers at Washington University School of Medicine in St. Louis has found that a high percentage of kids with ADHD are not receiving treatment. In fact, almost half of the children who might benefit from ADHD drugs were not getting them.

"What we found was somewhat surprising," says Richard D. Todd, M.D., Ph.D., the Blanche F. Ittleson Professor of Psychiatry and professor of genetics. "Only about 58 percent of boys and about 45 percent of girls who had a diagnosis of full-scale ADHD got any medication at all."


Much has been written about the increasing number of children taking drugs for ADHD. One study found that the percentage of elementary school children taking medication for ADHD more than tripled, rising from 0.6 percent in 1975 to 3 percent by 1987. Another study reported that the number of adolescents taking ADHD drugs increased 2.5 fold between 1990 and 1995. And many reports have noted a rapid increase in the U.S. manufacture of the stimulant drug methylphenidate -- usually sold under the brand names Ritalin or Concerta.

The researchers studied 1,610 twins between the ages of 7 and 17. Of those, 359 met full criteria for ADHD: 302 boys and 57 girls. The total number of boys in the sample was 1,006, and 604 girls were included.

"From a clinical point of view, this study affirms that for whatever reason, many children who could benefit from treatment are not receiving it," says first author Wendy Reich, Ph.D., research professor of psychiatry in the William Greenleaf Eliot Division of Child Psychiatry.

It's possible those children aren't being identified at schools or pediatrician's offices or that their parents are choosing not to put their children on stimulant medication, according to Reich.

"It may be that mental health professionals need to do a better job of explaining the risks and benefits of treatment," Todd says. "The vast majority of parents whose children were involved in this study reported that their kids improved with medication, and when used properly these drugs have been shown to be very safe."

Todd, who also is the chief of child psychiatry, says among the 1,251 kids in the study who did not have ADHD, some did take stimulant medications, but it was a very small percentage, only 3.6 percent of the boys and 2.6 percent of the girls.

He says, however, that in many cases, there's an understandable reason those children have sought treatment. The study found that most of the children without ADHD who took medication did have some symptoms of ADHD -- some hyperactivity or problems with inattention -- but not enough symptoms to meet formal diagnostic criteria as defined by the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-IV). The study also found that most of the kids who took medication without an ADHD diagnosis had a twin who did have the disorder.

"These children have what we might call subsyndromal, or mild, forms of ADHD, and they seemed to come from families where other children had full-blown ADHD," Todd explains. "We didn't find that children got these drugs because they had other problems, such as conduct disorder or a learning disability."

Reich says the eventual goal of studying twins is to learn what elements of ADHD are passed down in families. She says some aspects of the disorder are certainly genetic. Others may be related to environmental factors, and studying twins allows the researchers to tease out those influences. Todd says the hope is to identify genes that contribute to the disorder, or rather, the disorders.

"It's becoming clearer that ADHD is not a single problem but a group of disorders that have different causes but similar clinical expressions," he explains. "There also can be lots of reasons why you become diabetic or hypertensive. The end result is high blood sugar or elevated blood pressure, but how that happens can differ greatly from individual to individual. It's the same thing for ADHD."

Todd believes that as genes are identified, it may become possible to intervene in new ways -- with psychotherapies, environmental interventions or medications that affect biological pathways that haven't yet been identified. But he says a potential stumbling block in the future, as now, will involve getting children into treatment.

"That's especially true for girls because for whatever reason, less than half of the girls who had ADHD in this sample ever received treatment," Todd says. "As genes are discovered and treatments developed, they won't be able to solve problems unless they are used."

###

Reich W, Huang H, Todd RD. ADHD medication use in a population-based sample of twins. Journal of the American Academy of Child and Adolescent Psychiatry, vol. 45:7, pp. 801-807, July 2006.

This research was supported by the National Institute of Mental Health.

Washington University School of Medicine's full-time and volunteer faculty physicians also are the medical staff of Barnes-Jewish and St. Louis Children's hospitals. The School of Medicine is one of the leading medical research, teaching and patient care institutions in the nation, currently ranked fourth in the nation by U.S. News & World Report. Through its affiliations with Barnes-Jewish and St. Louis Children's hospitals, the School of Medicine is linked to BJC HealthCare.

Contact: Jim Dryden
Washington University School of Medicine
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Mixed populations in assisted living concerns advocates - Greensboro News-Record

By Eric J.S. Townsend
Staff Writer

GREENSBORO -- Russell Lane never stood a chance.

The former electrician, paralyzed from the waist down, was the city's first homicide victim of 2004 after authorities said a fellow resident at Arbor Care Assisted Living stabbed him four dozen times.

The accused attacker? A man who claimed to be God and who once was committed to a federal hospital after threatening to kill President Clinton.

The fatal stabbing, followed a year later by a similar incident in Alamance County, illustrates one of the biggest issues in the assisted living industry: mixing the mentally ill with the frail or elderly.

Many homes lack employees trained to handle the former. The latter have no say in who moves in down the hall. In extreme cases, like that of Arbor Care, that mixture is deadly.

Although some changes -- such as a process to screen potential residents for mental illness -- are under way, observers say the system serves both populations poorly.

And as North Carolina mental health reforms accelerate, psychiatric hospitals are discharging larger numbers of patients into communities.

A study published last year found that long-term care facilities are an "unavoidable choice" for the mentally ill, even though such homes are not designed to treat these people or help them achieve independence.

More than 40 percent of residents living in an assisted living home in North Carolina have a diagnosed mental illness.

"We paint everybody with the same brush," said Sabrena Lea, with the Piedmont Triad Area Agency on Aging. "That just doesn't work."

Several factors contribute to the risks of blending two populations:

• Homes often lack employees trained to recognize behavior linked to mental illnesses.

• Mentally ill residents, who tend to be younger, may find little planned activity geared to their age and will leave the home. Some leave the home, only to return drunk or high.

• Older residents can be intimidated by younger counterparts. While no statistics exist, Lea said, "shakedowns" for cash, cigarettes or personal property can occur.

"This is symptomatic of a bigger issue, that there are limited housing options for people with mental illness," said Ben Staples, executive director of the state office of the National Alliance on Mental Illness. "As one is discharged from a psychiatric hospital, the options are extraordinarily limited.

"There are nursing homes, adult care homes and homeless shelters. Frequently, the individual doesn't need to be in a nursing home. That's a level of care beyond what most people with mental illness need."

Limited options

Nearly one out of every four residents in a North Carolina adult care home is under age 60. Of that younger group, almost two-thirds have a mental illness.

How the homes got this way is not disputed.

For years, as advocates such as Staples point out, few housing options existed for anyone with a mental illness about to be released from an institution.

Assisted living homes, which help people handle basic needs such as eating, dressing and bathing, filled the void. Residents could live in such homes, many times alongside senior citizens, yet remain quasi-independent.

But many assisted living facilities give scant attention to the needs of younger, more mobile adults who are looking to integrate with the community.

Organized activities cater to the elderly. In common areas, friction can arise over issues as small as what to watch on television. Transportation at all but the priciest facilities is limited for those who want to work or travel.

A study group commissioned by the General Assembly made several recommendations in late 2005 for ways to improve long-term care services. Its final recommendations cited the inability of many homes to treat those with mental illness.

Among the suggestions:

• Develop a screening process for homes in which anyone applying to live there would have their mental health measured. Such a system could be based on a federally mandated screening for nursing homes.

• Hire mental health experts who visit adult homes to train staff on dealing with mental health issues as they surface in younger residents.

• Encourage local mental health agencies to strengthen relationships with adult care homes in their area to better refer residents with special needs.

Though no legislation was introduced by lawmakers following the December report, efforts are under way to develop a screening instrument that would help homes determine if someone has mental health issues.

The state's Division of Aging and Adult Services is also working with the commission that oversees police training to devise better lessons for officers on how to deal with residents of assisted living and nursing facilities.

The S.A.F.E. program -- Strategic Alliance For Elders in Long Term Care -- was first introduced late last year and is moving beyond a pilot program to show officers how to interview residents with mental illness and to collect evidence, among other things.

A little guidance

A standard screening process is something Kim Eason said would help families looking to place relatives in a home. Her father, who suffers from dementia, was referred to a home in Greensboro that was not a good fit for his condition.

At Friendship Care Assisted Living, Eason's father, Hubert Long, could wander away from the facility with little notice. The alarm meant to notify staff if he left the building did not work, she said.

"He was placed in a facility that does not handle Alzheimer's patients," she said. "It was just awful." Eason has since placed her father in a more appropriate home.

At Arbor Care, where Lane lived, one former resident said residents' low morale contributed to tension there, which was exacerbated by age differences and mental conditions.

Nor were there many activities offered that interested younger residents.

"It is an extension of Butner," said Ed Greviskis, referring to a state mental hospital, John Umstead Hospital, in Butner. Greviskis was not a resident at the time of Lane's stabbing.

"There are a lot of people who should still be there ... and they end up going back," said Greviskis, who now lives off Alamance Church Road in a smaller group setting.

Greg Wendling, an attorney for Arbor Care, disputes the assertion that the rest home is an "extension" of a state psychiatric hospital.

"When a person comes to a rest home, they don't stop going to a medical care provider. They have doctors, just like you do if you live in a house or an apartment," Wendling said. "They continue to see their outside medical care providers.

"Those are the people who make decisions about their fitness ... and continued medical care and treatment."

Greviskis, though critical of his former home, also said he was able to get help there for his bipolar disorder and back pain. Problems, however, outweighed the positives when it came to admitting residents, he said.

Midevening attack

Carl Porter spent three years in a Missouri mental institution after authorities arrested him for threatening President Clinton in 1994. The warden there, according to federal records, eventually deemed him well enough to be released -- provided he continue a "prescribed regimen of medical, psychiatric or psychological treatment."

Porter arrived at Arbor Care in 1998 and for years posed no problems. But shortly after dinner on Jan. 4, 2003, Porter entered Lane's room and stabbed him, authorities said. Bloody footprints trailed to Porter's room down the hall.

Police spent an hour trying to get Porter to surrender from his locked room before forcing their way in. He offered no resistance.

An attorney for Lane's family, which filed suit against Arbor Care, declined to comment and instructed her clients not to do so. The Lanes claim Arbor Care knew of Porter's dangerous mental condition and did not protect Russell Lane.

Wendling, Arbor Care's attorney, declined to comment on Porter or Lane, citing privacy laws.

He did, however, point to public records that indicate the stabbing was the first reported incident of violent behavior by Porter.

"Arbor Care feels this was obviously a terrible tragedy," Wendling said last week. "But bad things happen in society, too. The rest home is a microcosm of society that has, generally, an older population base.

"But you're still going to have incidents and occurrences, just like you do in society."

Porter refuses to talk with psychiatrists and his own public defender. Should he ever be found competent to stand trial, authorities will move him back to Guilford County.

For now, advocates for adult care homes and for the mentally ill hope the study -- and recent steps toward implementing suggestions -- are not forgotten by lawmakers.

The state allocated $95 million dollars in new funding this spring for mental health reform. Hopefully, advocates say, that money will trickle into adult care homes where people with mental illness live.

"This is probably the largest infusion of funding into our public mental health system in decades, and maybe in forever. ... And next year we'll need more," said Robin Huffman, executive director of the N.C. Psychiatric Association.

"While we're thrilled," she said, "we're panicked that legislators will brush their hands off. 'Well, we took care of mental health.' "

Contact Eric J.S. Townsend at 373-7008 or etownsend@news-record.com

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Adult-Care closure may be off table - Charlotte Observer

Possible penalties at adult-care home: Maximum $20,000 fine, no new admissions

KYTJA WEIR AND ERIC FRAZIER

Social services officials are considering asking for the maximum fine of $20,000 and the suspension of new admissions at a Cleveland County adult-care center whose missing patient was found dead last month.

The news that regulators might not close the Unique Living facility near Lawndale disappointed advocates for disabled people and relatives of Kelly "Buck" Whitesides.Eric Frazier: 704-358-5145


"I think that is the lowest thing they could do," his sister, Deborah Llewellyn, said Friday. "I can't see why the place should not be shut down."

Unique Living might escape closure because state regulators say they can't consider a deadly history of rule violations at the site.

Those problems came under different ownership. That gave new management a clean slate, even though the former owners' son and program director oversee the newly renamed business.

Whitesides walked away from the center on July 30. The 59-year-old former mill worker, who suffered from dementia and diabetes, had a history of wandering. He was found dead six days later in woods near the facility.

The Cleveland County Department of Social Services, which has been investigating the death, on Friday revealed its preliminary findings and possible penalties.

Teala McSwain, Cleveland County DSS's adult and community services program manager, said her office isn't considering shutting down Unique Living because the current center's compliance record isn't bad enough.

She said the DSS only recommends such action if the center has a variety of offenses over a long period. Other problems at the site occurred but under a different name and ownership.

Unique Living, which opened in March 2005, occupies the same site as Yelton's Health Care. One Yelton's resident died after being scalded in a tub, and another fatally choked on a Spam sandwich. A convicted sex offender also raped a fellow resident there.

Donald and Joan Yelton, who owned the old center, still own the property. The new center is owned by their son, Jamie Yelton, and Dana Head, who lives with him. A third owner was the programming director for Yelton's Health Care.

Neighbors have told the Observer they see little difference. The home's residents still wander around the area at all times of night, they say.

But Unique Living has a new license. By law, county and state officials cannot lump the past record from Yelton's Health Care with Unique Living, McSwain said.

Asked whether the record of Yelton's Health Care plus Whitesides' recent death would have been grounds for shutting down the home, McSwain told the Observer: "I don't know."

County DSS officials met with Unique Living's owners Friday to discuss the preliminary findings. McSwain, who said she did not attend the meeting, said the owners were cooperative.

The owners of the home did not return calls Friday afternoon. And a woman who answered the on-duty supervisor line there declined to comment.

Investigators believe the home's supervision was "inadequate," McSwain said.

Whitesides had only been at the home for a few days when he disappeared, but he had wandered off earlier that day. The home did not notify authorities that he was missing the first time. He ended up in Cherryville. When police tried to alert the home that Whitesides had been found, no one there answered the phone.

Once Whitesides was back at the center, McSwain said, the staff stepped up supervision. Investigators found inconsistent information about whether they checked on him every 15 or 30 minutes, she said. But either way it wasn't enough, she said, because he got away. DSS recommended that the owners:

• Improve phone procedures to make sure staff doesn't miss emergency calls.

• Give more detailed information to law enforcement about medical concerns when someone disappears. Whitesides needed daily medication, but McSwain said staff provided only "limited" information the final time he disappeared. The Cleveland County Sheriff's Office did not conduct a formal search for six days.

• Improve emergency procedures so all staff know to consider how residents' medical conditions might affect their safety.

• Improve the admissions process so staff knows more about the residents' medical conditions, needs and habits. Unique Living received hospital reports showing Whitesides had dementia only after he was found dead, McSwain said.

The preliminary recommendations begin a detailed process that gives the owners a chance to respond and improve conditions. State and county officials, meanwhile, are still looking into neighbors' complaints about residents wandering around.

Ultimately the N.C. Division of Facility Services, which regulates such sites, will decide what penalty to levy.

Whitesides' wife, Linda, called $20,000 a "little" fee and dismissed the idea of blocking new residents from the center. "How about the patients already there?" she asked.

"This is not going to stop at that because I'm not going to let it," she said.

One advocacy group for disabled people called for the site to be shut down as far back as 2000. On Friday, the head of the Governor's Advocacy Council for Persons with Disabilities reiterated her call for the site to be shut down.

"It makes me sick that we have another episode here," said Allison Breedlove, interim executive director for the council. "The penalties are not strong enough, especially for repeaters."

What Happens Next

• Friday's announcement set a 45-day clock in motion for Cleveland County Department of Social Services to write a report and for the owners of Unique Living to respond. That information will then go to state officials who have final authority on issuing any penalties.

• The Cleveland County Sheriff's Office is still waiting to learn what killed Buck Whitesides. An autopsy was conducted, but toxicology results are still pending.


kweir@charlotteobserver.com
efrazier@charlotteobserver.com


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Mental health reforms stir justifiable fears - Greensboro News

Letter to the Editor August 17, 2006

By Mona Shatell

Mental health care reform in North Carolina is a difficult process for all involved -- mental health service recipients (consumers), mental health care providers, state policymakers and the wider community.

Mike Moseley, in his Counterpoint on Aug. 9 ("Many mental health reform fears unjustified"), articulated this challenge well. His response to the July 16 editorial, "Mental health overhaul worries many," provided optimistic expectations of reform by sharing favorable responses from other communities that are further along in the reform efforts.

Change is hard and naturally causes doubt and uncertainty.

However, I take issue with the way Mr. Moseley minimized mental health service recipients' fears -- fear that uncertainty undoubtedly breeds.

These fears are multidimensional and rooted in a long social, historical and cultural history of inequality, stigmatization and marginalization of people with mental illness. If mental health parity existed, and if our society did not discriminate against individuals with mental illness, these fears might in fact be "unjustified."

But, Mr. Moseley, this is not a world we currently live in, and because you are the director of the N.C. Department of Health and Human Services, Division of Mental Health, Developmental Disabilities and Substance Abuse Services, it is a world that I expect you to know.

I wonder, was your response from a lack of understanding of the multidimensionality of the issue or a defense against your own uncertainty?
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Used properly, Tasers save lives - Asheville Citizen-Times

published August 18, 2006 12:15 am

An Asheville police officer demonstrated how valuable Tasers can be as a law enforcement tool when he used one earlier this week to subdue a woman threatening officers with knives.

Critics have objected to the use of Tasers, saying they are used too often and that, in rare instances, people shot with Tasers have died.

But the Asheville case demonstrates that, when used appropriately, the potential for saving lives makes Tasers an essential weapon in officers’ arsenal.

Officers were serving involuntary mental commitment papers to a 48-year-old woman at her home off Dysart Street when she became enraged and charged officers with a pair of 10-inch knives.

“If it hadn’t been for the Taser in that situation the results would have been pretty tragic,” West District commander Lt. David Rutledge said. Police were trying to talk the woman, who had already inflicted knife wounds on herself, out of a trailer when she charged them. Officer Josh Biddix used a Taser when she was 8 to 10 feet away.

If they had not had the Taser, officers would have had to resort to the use of deadly force, according to Rutledge.

That would have meant that to protect themselves and their fellow officers, they would have been forced to seriously injure or kill someone whose only real crime, so far as has been reported, is to be sick and in need of medical treatment for mental illness.

The result would have been enormous suffering for the family of the mentally ill person and, undoubtedly, anguish on the part of the police officers, as well.

Use of a stun gun allowed police to subdue the woman without serious harm to her and to make it possible for her to get the medical help she needs.

Asheville police were criticized in March 2005 after an officer used a Taser three times on a woman checking on her neighbor’s dog. Resisting arrest charges against the woman were later dropped and the officer was fired.

Any tool can be misused and that is precisely what happened on that occasion. The department responded appropriately in removing the officer responsible.

Officers are trained in the use of Tasers, a process that requires Tasers to be used on the officers to show the effects firsthand. They are also trained in the department’s policy for the use of the stun guns, which fire a blast of up to 50,000 volts of electricity. When used appropriately and according to department policy, Tasers should be seen for what they are, a tool that can prevent suffering and save lives. Read more!

Questions raised by rest home death just get more disturbing - Charlotte Observer

The case of Kelly "Buck" Whitesides just keeps on revealing troubling facts about how North Carolina cares -- or doesn't -- for people who can't care for themselves.

The most recent: More than 40 percent of the people in N.C. adult care homes and nursing homes are mentally ill, but state regulations for the facilities are written as though they're treating only the elderly.

As a story in Thursday's Observer reported, many of the homes aren't staffed or trained to care for mentally ill residents. That means the residents get no treatment for illness and it puts other residents at risk.

That was certainly the case at Unique Living, a Cleveland County adult care home where Mr. Whitesides, 59, died last month after he wandered off twice in one day. His body was found nearby six days after he disappeared.

On its state licensing forms, the home reported last September that 76 of its 77 residents had mental illness. Neighbors told the Observer they've complained for years about home residents wandering around and making nuisances of themselves.

Some of the questions the case raises apply to Unique Living and Cleveland County:

• Why didn't the home report him missing the first time he left? He suffered from dementia and diabetes, relatives said. When police found him and tried to notify the home, why didn't staffers answer the phone?

• When he disappeared again, why didn't the county sheriff's department launch a thorough search? A deputy checked nearby roads, but no search dogs were called in until six days later.

Other questions target the adequacy of state supervision of such homes:

• Why is the home even allowed to stay open? Unique Living is on the same property as a previous home, Yelton's Health Care, owned by Joan and Donald Yelton. Yelton's racked up a horrifying list of violations. One resident died when she choked on a Spam sandwich. Another died after she was scalded in a too-hot bath. Yet another resident, a convicted sex offender, was charged with raping a fellow resident.

In 2005, Yelton's closed and Unique Living took its place, without closing even a day. The Yeltons still own the property. The new business is owned by their son, his live-in girlfriend and the programming director of the old home, who holds that jobs with the new one.

• Why do state regulations allow that kind of licensing evasion? Here's something even scarier: North Carolina has tightened its rules on that front and is even considered a national model. Yet those "tighter" rules still let the Yelton family repackage its troubled home to get a new license.

• Why hasn't the state acted to improve care of mentally ill people at adult care homes? After a state commission studied the problem of mentally ill people at adult care homes that aren't equipped to care for them, its recommendations for improving care appear to have fallen into a bureaucratic black hole.

You can tell a lot about a society by the way it treats those who can't take care of themselves. We should all be horrified at what Buck Whitesides' death reveals about North Carolina. Read more!

Care rules may not suit mentally ill - Charlotte Observer

They pose more challenges in homes, but state regulations meant for elderly

ERIC FRAZIER AND KYTJA WEIR

More than 40 percent of the people in adult-care homes and nursing homes across North Carolina are mentally ill, but outdated state rules still regulate the centers as if they treated only the elderly.

That leaves hundreds of facilities across North Carolina understaffed and untrained for the challenge of handling mentally ill residents, according to a state report.

Authorities say such homes are ill-equipped to handle patients such as Kelly "Buck" Whitesides, the 59-year-old man who wandered away from a Cleveland County adult-care home last month and was found dead in nearby woods.

"Unless there is major change ... we're going to have a lot more people wander off and die," Cleveland County DSS Director John Wasson said. "You basically have an unlicensed mental hospital operating with the license of an old folks' home."

Whitesides suffered from dementia and diabetes, according to relatives. Authorities said the 80-bed facility, Unique Living, had five people on staff at the time, though state rules called for just four.

That wasn't enough, Wasson said, considering the more challenging behaviors of the mentally ill. Those patients, whose behavior can put themselves or others at risk, require closer supervision than frail, elderly people. But the state's adult-care regulations were set up to meet the needs of geriatric patients, not the mentally ill, Wasson said.

Unique Living, for instance, stated on its state licensing forms that 76 of the 77 patients it housed in September 2005 had mental illness, and two had Alzheimer's or dementia.

Considering that, Wasson said, even 12 staffers wouldn't have been enough.

Report to state legislators

The problem isn't new. Adult-care homes began stepping up to care for mentally ill people decades ago as mental health experts decided patients would be better off in smaller, community-based centers rather than large state mental hospitals.State officials and health care providers have debated for more than a decade how best to supply long-term care for mentally ill patients, who often are sent to such homes by social workers, mental health agencies and other health care providers.

In 2004, N.C. lawmakers asked for a study of the issue. The N.C. Department of Health and Human Services convened a group that offered solutions in December 2005.

The group's report asked lawmakers to:

• Improve the training for adult-care workers.

• Upgrade staffing levels to give direct care workers more time with residents.

• Spend $2.4 million annually for 37 trainers who can teach workers how to handle mentally ill residents.

However, the lawmakers who received the report -- members of a special commission on aging issues -- didn't include its recommendations in bills they put forth for the General Assembly to consider.

"We were asked to do a report. We did it and they received it," said Jackie Sheppard, a deputy secretary in DHHS. "There may have been a brief discussion of it. But that was it."

It wasn't immediately clear what, if anything, happened to the recommendations.

Calls to the co-chairs of the legislative commission -- Sen. Charlie Dannelly and Rep. Beverly Earle, both Mecklenburg Democrats -- weren't returned Wednesday. They were attending a conference in Tennessee for state lawmakers, according to Dannelly's secretary and another lawmaker.

Rep. Bob England, a Rutherford County Democrat who also serves on the commission, didn't recall any legislation coming from the report.

"I wish I could answer your question," he said. "I do not recall any specific meeting we held to specifically discuss that report."

England said he had come across the issue in his 42 years practicing family medicine. He would prefer to separate the populations in adult-care homes. But he added, "The kind of funding necessary is not yet there."

Another member of the commission, Rep. Alice Bordsen, D-Alamance, is the chair of the House Committee on Aging. She called it a tough problem, but added that she also wasn't sure what happened to the recommendations. "I think that issue is yet to be dealt with."

State, not federal, oversight

Adult-care homes come in various shapes and sizes across the country, often lumped together under the term assisted-living centers. Unlike nursing homes, which provide a higher-level of medical care, they don't face federal oversight. Instead it's up to each state to craft rules and requirements. And it's a growing industry that treats increasingly different needs.

A 2003 U.S. General Accounting Office report called for more federal oversight of such state programs because the amount of Medicaid spending on patients was increasing. GAO inspectors found problems with the quality of care in more than 70 percent of the cases it reviewed.

While North Carolina is developing more appropriate institutions, the state report says adult-care homes and nursing homes will remain "an unavoidable choice" for mentally ill patients until that process is complete.

`Recipe for disaster'

Long-term care experts say mixing residents of widely diverging ages and needs is a bad idea, but no state law or rule prevents it.It's hard to train staff to meet the needs of a 35-year-old mentally ill man and a frail 85-year-old woman, said Jerry Cooper, who leads an industry trade group. The activities, social functions, even the menus must be different.

"It's a recipe for disaster," said Cooper, head of the N.C. Assisted Living Association. "I've been on my soapbox many times, but it never seems to go anywhere."

Cleveland County officials have been asking state authorities for years to help them stop mentally ill patients from being placed on the site Unique Living occupies.

Cleveland DSS officials complained in a 2004 letter that hospitals, jails and prisons had been sending severely and persistently mentally ill people -- including those with criminal backgrounds -- to Yelton's Health Care, the center that previously operated on the site.

In one three-month period, the letter said, officers responded to about 90 calls for a variety of incidents.

Eric Carlson, a California-based attorney specializing in long-term care at the National Senior Citizens Law Center, said it's common to see mixed populations of young mentally ill patients housed with older people in such homes around the country.

Often, he said, a facility that is starting to go downhill has difficulty filling its beds. It starts to find mentally ill people to fill the gaps. That can lead to young, potentially more aggressive populations sharing the same space with an older more vulnerable group.

"Oftentimes it's a bad fit," he said.

What is an Adult-Care Home?

Aging adults who can't live on their own have many different options. There are about 1,300 adult care homes in North Carolina, and more than 300 nursing homes

Adult-care homes -- sometimes referred to as rest homes -- generally provide assistance with the activities of daily living such as dressing, bathing, eating and supervision. Such homes fall into two categories - family-care homes that provide care to fewer than seven adults and adult-care homes such as Unique Living that has 80 beds. The state and county Department of Social Services offices regulate them. Nursing homes, on the other hand, provide care for those with greater medical needs and face state and federal oversight.

NEED HELP?

Both Carolinas have hot lines to field complaints about nursing and adult-care homes:

• In North Carolina, call 800-624-3004.

• In South Carolina, call 800-868-9095.

Eric Frazier: 704-358-5145; Kytja Weir: 704-358-5934.

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New look at adult care rules - Charlotte Observer

N.C. legislative panel that failed to consider reforms should revisit issue, co-chair says

ERIC FRAZIER

efrazier@charlotteobserver.com

The co-chair of a N.C. legislative panel that failed to make reforms proposed for adult care homes earlier this year now says she's rethinking the issue.

Beverly Earle, a Mecklenburg Democrat who co-chairs the N.C. Study Commission on Aging, acknowledged Thursday that she and other lawmakers didn't take legislative action after receiving a report critical of the way the state handles mentally ill residents in adult care homes.

The Observer detailed the report Thursday, along with concerns by officials who say adult care homes are too understaffed and ill-trained to safely handle the thousands of mentally ill people living in them.

Reached at a state lawmakers' convention in Tennessee, Earle said her group needs to revisit the report's recommendations when it meets again, possibly as early as next month.

"We didn't do any (legislative) recommendations directly from that," Earle said. "I definitely think we should go back and re-evaluate the situation."

Officials from the state health and human services department presented the report's findings to lawmakers in February. They found that more than 40 percent of the people in rest homes and nursing homes across the state are mentally ill, but the state still regulates the centers as if they housed only the elderly.

That, the report said, leaves the homes understaffed and without proper training to deal with the safety concerns presented by mixing the elderly and the mentally ill -- particularly younger mentally ill people.

The report recommended a number of reforms, including spending $2.4 million a year to hire 37 trainers who can teach long-term care workers how to handle mentally ill residents.

The legislature, in its current budget, earmarked more than $90 million for mental health programs. Earle suggested some of that money might be shifted to deal with the adult care problem.

"I'm not saying that's what we will do," she said. "Some of it may already be earmarked for mental health issues that deal with the elderly. We need to go back and look at what we can do that makes sense."

The mentally ill and those with Alzheimer's and dementia have been flowing into adult care homes for years, even though the homes are designed for the elderly. Also known as rest homes, the approximately 1,300 N.C. centers provide 24-hour supervision, meals and social activities for residents, but don't offer as much medical care as nursing homes.

Experts say the state needs more facilities designed for the mentally ill. They believe mixing the mentally ill with fragile elderly people puts the elderly at risk and leaves mentally ill people without proper supervision.

The state tried to address the problem as far back as 1999, when the General Assembly passed a law allowing special care units for the mentally ill and those with Alzheimer's to be created inside adult care homes.

But lawmakers didn't increase the reimbursement rates to help adult care homes support the additional staff and training required, according to Jerry Cooper, head of the N.C. Assisted Living Association, a trade group.

There are few, if any, such units in North Carolina, Cooper said. He and others in the industry say centers that house Medicaid patients can't afford them. That could change in October, when a higher state-approved reimbursement rate for Alzheimer's units kicks in.

In recent months, several people with Alzheimer's or dementia have wandered away from nursing homes or adult care facilities and have later been found dead.

Last month, 59-year-old Kelly "Buck" Whitesides wandered off from a Cleveland County adult care home called Unique Living and was later found dead in nearby woods.

Relatives say he suffered from dementia. Results of a state investigation into his death are expected today.

Adult care homes "will continue to have problems and even deaths until the General Assembly addresses it in a comprehensive way," Cleveland County DSS Director John Wasson said. Lawmakers "have a great opportunity to strike a blow to help people with mental illness Read more!

Mental health reform has yet to deliver what it promised - Asheville Citizen-Times

Letter to the editor

by Diane Bauknight

Regarding the guest commentary, “A case shows mental health system can work,” (AC-T, July 18). Most families would not consider a group home placement followed by foster care a desirable outcome for their child. The mental health reform promised a rich array of community-based services that would allow people to receive treatment in their homes and communities. As a bonus, the state would save money. Where were these community-based services (including crisis care) that could have allowed this child to remain in her home instead of being bounced through two homes, into a group home and then into foster care?

Instead of realizing the promises of the reform, more and more children are being placed in group homes, institutions and foster care while the state blindly goes about the business of gutting community-based services and dismantling our state mental health facilities. This has heaped trauma, misery and tragedy for families trying to keep (and treat) their mentally ill children at home.


Diane Bauknight

Fairview Read more!

Adult-Care Violations Lead to Deaths - Raleigh News & Observer

Thomas Goldsmith, Staff Writer

More than 50 people living in adult-care homes in North Carolina died recently after preventable mistakes. State records say that inattentive care, medication errors and poor maintenance of the homes contributed to the deaths over a five-year period.
Residents of these assisted-living facilities, rest homes and family-care homes have choked to death, frozen, been scalded and wandered into traffic, according to reports on file with the state Division of Facility Services. One suffered a fatal stabbing by a fellow resident. Another received the blood thinner Coumadin for five days instead of Claritin, an allergy medicine.

In each case, the deaths arose out of "something the facility did or failed to do," said Jeff Horton, the division's chief operating officer.

For about 27,000 North Carolinians living in adult-care homes, the death rate after these preventable incidents is more than six times that of state residents over age 65 who die from health-care complications such as surgery gone wrong.

Just this month, a 59-year-old Alzheimer's patient in Charlotte was found dead almost a week after walking away from a Cleveland County rest home. And last month, Winston Prince, 64, walked away from Parkway Retirement Home in Cary -- while a county inspector was conducting a review there. Prince was found alive nine hours later, after apparently hitchhiking to Fuquay-Varina.

"The folks who are in long-term care, they are a frail elderly population, and you expect some deaths," said Bill Lamb of the UNC-Chapel Hill Institute on Aging. "You don't expect deaths where the staff of the facility is culpable."

These cases, in which people died after the staff or home committed serious violations, are just the ones reported to the state. Advocates for residents say more occur without notice. Outside of family and government, the deaths rarely get attention. A change in state law last year resulted in reduced public access to investigations and information about penalties in the cases.

Jerry Cooper, executive director of the N.C. Assisted Living Association, a trade group, called the deaths tragic.

"We need to kind of step back and look at the big picture and see what system could have been in place," he said.

Under the law, county and state investigators propose fines for violations that include negligence, medication errors and improperly maintained buildings. But these fines are lowered or dismissed in about 38 percent of the cases, an analysis by The News & Observer has found. The average fine paid in these cases was about $2,615.

Since 2000, the state has dealt with 67 cases of preventable deaths in adult-care centers. The N&O analyzed 53 cases for which complete data were available and the most serious level of violation occurred, according to state records.

Industry representatives and advocates for older people point out that many adult-care homes do a good job caring for residents. Horton said that problems can often be traced to poor staff training, high turnover and the placement of residents in homes that aren't equipped to care for them. Industry representatives say state Medicaid reimbursement rates should be raised to better cover the increasingly complicated care that patients require.

Clearly, the growing industry is in flux, and state regulations often struggle to keep up. Changes to state law in 2005 increased some fines to as much as $20,000 and added inspectors for the adult-care industry; each facility will be inspected annually beginning next year.

In the same session, though, a provision quietly added to the state budget bill at the last minute cut the monthly meetings of the Penalty Review Committee to twice a year. This state-appointed advisory committee is seen by advocates for older people as a key means of opening the regulatory process to families and the public.

Betty Broadhurst of Rocky Point, a former committee member, predicted that the changes would be harmful to elderly residents.

"There will be no advocacy," she said. "There will be no voice for these people."

Even before the 2005 change in the law, some relatives of people who died in assisting-living homes got angry at what they called the state's inadequate punishments. Tommy Laughter of Hendersonville appeared in 2004 before the Penalty Review Committee to argue that the Brevard rest home where his mother lived should be fined $10,000 -- then the maximum.

"We went to Raleigh with the intention of letting my case be heard in front of the board and to find the justice that we thought my mother deserved," said Laughter (pronounced LAW-ter).

Lois Laughter died after a long day of vainly pleading to be taken to a local emergency room. An emergency-medicine doctor who examined the records later said an earlier trip to the ER would have saved her life, state records show. A lawsuit said Laughter had gone three days without a bowel movement before she died. The case was resolved before trial.

The penalty committee recommended a $2,000 fine, but the Division of Facility Services later dismissed it; no fine was paid. The Brevard assisted-living facility, the Parc, is now under different ownership. Representatives of the Parc did not respond to requests for comment.

"I didn't want my mom's life and character and legacy to be lost in vain," Tommy Laughter said. "In a lot of ways, you can argue that she was lost in vain."

Rest homes get bigger

Twenty years ago, rest homes in North Carolina were often home-like operations -- small businesses that housed 16 or so older residents, said Florence Soltys, a UNC-Chapel Hill expert on aging.

"They made a living," Soltys said, "but it wasn't to pay off stockholders."

As people lived longer and nursing homes grew crowded, large chains that ran nursing homes have branched into assisted living to capitalize on an economic opportunity. Many built large homes, with 100 beds or more.

Growth has exploded just in the past few years, said Joshua Wiener, who is working on the first nationwide survey of the assisted-living industry for the Research Triangle Institute.

Nationally, there could be as many as 1 million people in adult-care homes, compared with about 1.5 million in nursing homes, Wiener said. The number of adults in North Carolina needing care is estimated to have increased by about a third over the past 15 years.

"People are looking for alternatives for nursing-home care, one that ideally involves more choice for the residents and is more homelike and less expensive," Wiener said.

Nursing homes, with a higher percentage of sicker residents who require skilled nursing care, have received more federal money. But that comes with strings attached -- more regulation. Federal rules require them to have a nurse on duty and, generally, to have roughly one worker for every 10 residents.

Adult-care homes generally have only a certified supervisor and one aide per 20 residents during day shifts, and one aide per 30 residents at night. A state program to be announced later this month is designed to reduce high rates of turnover among direct care workers by recognizing centers that voluntarily meet higher standards.

Increasingly, rest homes have been taking in sicker residents, even though staff training is often minimal and pay is typically low. Among those who are entering rest homes are people with mental illness -- and they're often much younger than other residents.

"I don't think with the personnel that they have and the ratio [of caregivers to residents] that they are able in many instances to give adequate care," said Soltys, the UNC expert, of the state's adult-care homes.

Judy Jeffreys agrees. Her brother, Troy Stephens, drowned in a lake in 2004 after walking away from the Meadows of Garner, an assisted-living facility. Stephens, who had lived there at least four years, had been diagnosed with schizophrenia, heart disease and other illnesses.

Wake County officials said then that Stephens' case illustrated problems with adult-care homes that house residents with different types of physical and mental disabilities.

"I just don't think any of them do a very good job," Jeffreys said. "They have had too many walk away and die. They can pay a penalty and stay in business, and that's what they do."

Jeffreys' husband, Phil, a Wake County commissioner, doesn't think much of the current fines; none was ever paid in Troy Stephens' case. Phil Jeffreys said the worst cases ought to prompt criminal charges, but such drastic measures are rarely taken.

"This is something that really needs to be looked at, to hold some of the people that own these homes criminally liable," he said.

$12,000 fine pending

On Thursday, the state's Penalty Review Committee met for the second time since October. Under the law passed last year, residents or family members must request a hearing if they want to press a complaint sooner than the committee's twice-yearly meeting.

The panel considered the case of Herbert Moore Sr., 86, a former longshoreman who wandered away from an assisted-living home in Elizabeth City the day after Christmas last year. Searchers found his body Dec. 30 in the woods, several hundred yards from the Carolina House rest home. Moore was still clad in pajamas and slippers.

His relatives demanded that the committee move forward the $12,000 fine recommended by county investigators. They won, but the fine could still face appeals.

A similar incident occurred in May, when Mickey Ankhelyi, 67, walked away from Wake Forest Care Center, an assisted-care facility. Ankhelyi was found dead the next day, half-submerged in a nearby creek. His family has declined to comment.

"When you don't have locked facilities, it's just really hard," said Richard Cresenzo, the center's owner. "It's really something that's almost impossible to monitor perfectly."

During a tour of the center last month, Cresenzo and director Sherry Grady said that Ankhelyi, an Alzheimer's patient, was quite mobile and determined to get out of the facility in the weeks before his death.

"We all want the same thing," Cresenzo said. "We want it not to happen again."

(News researcher Paulette Stiles contributed to this report Read more!

Planned Medicaid Cuts Cause Rift With States - New York Times

August 13, 2006

By ROBERT PEAR
WASHINGTON, Aug. 12 — The White House is clashing with governors of both parties over a plan to cut Medicaid payments to hospitals and nursing homes that care for millions of low-income people.

The White House says the changes are needed to ensure the “fiscal integrity” of Medicaid and to curb “excessive payments” to health care providers.

But the plan faces growing opposition. The National Governors Association said it “would impose a huge financial burden on states,” already struggling with explosive growth in health costs.

More than 330 members of Congress, including 103 Republicans, have objected to the plan. A letter signed by 82 House Republicans says it “would seriously disrupt financing of Medicaid programs around the country.” A bipartisan group of 50 senators recently urged President Bush to scrap the proposed rules, which were set forth in his 2007 budget and could be issued before the end of this year.

Medicaid finances health care for more than 50 million low-income people, with money provided by the federal government and the states.

Under the White House plan, the federal government would reduce Medicaid payments to many public hospitals and nursing homes by redefining allowable costs. It would also limit the states’ ability to finance their share of Medicaid by imposing taxes on health care providers. About two-thirds of the states have such taxes.

The federal government pays at least 50 percent of Medicaid costs in each state and more than 70 percent in the poorest states. Bush administration officials say states have used creative bookkeeping and accounting gimmicks to obtain large amounts of federal Medicaid money without paying their share. Moreover, they contend, some states have improperly recycled federal money to claim additional federal Medicaid money.

“States have managed to draw down more federal Medicaid dollars with fewer state dollars,” said Dennis G. Smith, director of the federal Center for Medicaid and State Operations.

State and local officials, members of Congress, hospitals, nursing homes and advocates for poor people make several arguments. First, they say, Mr. Bush is doing by regulation what he unsuccessfully asked Congress to do by legislation in the last two years. Second, they say, prior administrations and the Bush administration itself approved many of the state taxes that would be deemed improper under the new rules.

Gov. Arnold Schwarzenegger of California, a Republican, said, “The administration is attempting to reverse decades of federal Medicaid policy through the regulatory process,” less than a year after “Congress rejected these misguided cuts.”

In Missouri, Gov. Matt Blunt, a Republican, said the change “could mean a loss of more than $84.9 million” for his state. That, he said, would “jeopardize the continuity of care for Medicaid recipients” and set back efforts to improve care in nursing homes.

Gov. M. Jodi Rell of Connecticut, a Republican, protested the White House plan in a letter to Mr. Bush. She said the effects would be “disastrous” in states like Connecticut, which relies on fees collected from nursing homes to help pay its share of Medicaid costs.

Democratic governors, including Janet Napolitano of Arizona, Edward G. Rendell of Pennsylvania and Kathleen Sebelius of Kansas, also denounced the White House plan. Ms. Sebelius said the cuts would make it much more difficult for health care providers like the University of Kansas Hospital to serve Medicaid recipients and people without insurance.

The cuts contemplated by the White House would not reduce the cost of care. But state officials said the changes would put pressure on states to reduce Medicaid benefits, restrict eligibility or lower payments to health care providers.

Medicaid is one of the largest, fastest-growing items in state budgets. To pay their share of the costs, states often rely on general revenue from sales and income taxes. But many also levy special taxes on hospitals, nursing homes and other health care providers. In many cases, providers willingly pay such taxes because the revenue shores up Medicaid and can be used by states to obtain federal matching payments.

Under current rules, a state can impose a tax equal to 6 percent of the revenue of a hospital or nursing home. The administration wants to lower the allowable tax rate to 3 percent. The federal government would reduce its Medicaid payment to any state that levied taxes above that.

Michael O. Leavitt, the secretary of health and human services, said this change would “remove incentives for states to shift the responsibility to fund their share of the Medicaid program to health care providers.” Hospitals and nursing homes, he said, should welcome the change because it would reduce their taxes.

But Thomas P. Nickels, senior vice president of the American Hospital Association, and Bruce A. Yarwood, president of the American Health Care Association, a trade group for nursing homes, said the plan was simply a way to cut Medicaid.

“If provider taxes are cut, the Medicaid program will be reduced, and that will harm beneficiaries,” Mr. Nickels said. “We do not see a political will, at the federal or state level, to supplant provider taxes with other types of revenue.”

In February, Mr. Bush signed a bill that gave states power to revamp Medicaid by altering eligibility and benefits. That measure is expected to cut the growth of federal Medicaid spending by $4.9 billion over five years. The White House estimates that the new rules will save the federal government even more: $12.2 billion over five years.

The administration said it needed to impose stricter limits on Medicaid payments to public hospitals and nursing homes because such payments far exceeded “the actual cost of services” in many states.

The changes may seem technical. But Marvin R. O’Quinn, president of Jackson Health System in Miami, said they would directly and adversely affect patients.

Dr. Bruce A. Chernof, director of the Los Angeles County Department of Health Services, said the cuts would “reduce access to services in a county where 33 percent of residents are uninsured.” The county’s five public hospitals operate trauma centers and burn treatment units for all patients, not just Medicaid recipients, he said.

The effects are magnified by the way Medicaid is financed. For each dollar that a state loses in provider tax revenue, the federal government will reduce its contributions — by $1 in California and Connecticut, and by $3 in a poor state like Mississippi.

The White House said Mr. Bush would also adopt stricter policies on Medicaid payments for rehabilitation and school-based health services. Read more!

Mother of Terry Jackson Evans expresses feelings about shooting of son by police - Asheville Citizen-Times

I am the mother of Terry Jackson Evans, the 17-year-old boy shot and killed by a sheriff's deputy on July 13.

I called 911 after a statement Terry made that bothered me. Little did I know what was coming. That night my life came to an end, too. I had called for help for him, and when I saw the deputy point the gun and shoot him, I saw then my son's eyes and I knew what I had just done tot him when I called 911. I asked myself, "How am I going to live with myself for what I have done?" What does the deputy who fired the gun get for what he had just done? Well, he gets to go home to his kids, and gets time off with pay and then goes back to work like nothing happened. I think if law enforcement officers kill they should pay a price, like we do. If they shoot someone, and get time off and get paid for it, its kind of like saying, "Go out and kill. You will not go to jail for it, but you will get a lot of time off with pay." Thats why they are gun happy. My son was a normal 17-year-old, who did make a mistake when he shot up in the air and told them to leave. He never wanted to hurt anyone. I had only one kid, and I lived every day for him and wanted the best for him. His last words to me were, "Promise me you will always love me." I can't sleep because I see him being shot and I hear him asking me to always love him.

See what can happen when you call 911? Tammy Revis, Leicester Read more!

Experimental Medication Kicks Depression in Hours Instead of Weeks - NIMH

NIMH Press Office
301-443-4536

People with treatment-resistant depression experienced symptom relief in as little as two hours with a single intravenous dose of ketamine, a medication usually used in higher doses as an anesthetic in humans and animals, in a preliminary study.

Current antidepressants routinely take eight weeks or more to exert their effect in treatment-resistant patients and four to six weeks in more responsive patients — a major drawback of these medications. Some participants in this study, who previously had tried an average of six medications without relief, continued to show benefits over the next seven days after just a single dose of the experimental treatment, according to researchers conducting the study at the National Institutes of Health's National Institute of Mental Health.

This is among the first studies of humans to examine the effects of ketamine on depression, a debilitating illness that affects 14.8 million people in any given year. Used in very low doses, the medication is important for research, but is unlikely to become a widely used clinical treatment for depression because of potential side effects, including hallucinations and euphoria, at higher doses. However, scientists say this research could point the way toward development of a new class of faster- and -longer-acting medications. None of the patients in this study, all of whom received a low dose, had serious side effects. Study results were published in the August issue of the Archives of General Psychiatry.

"The public health implications of being able to treat major depression this quickly would be enormous," said NIH Director Elias A. Zerhouni, M.D. "These new findings demonstrate the importance of developing new classes of antidepressants that are not simply variations of existing medications."

For this study 18 treatment-resistant, depressed patients were randomly assigned to receive either a single intravenous dose of ketamine or a placebo (inactive compound). Depression improved within one day in 71 percent of all those who received ketamine, and 29 percent of these patients became nearly symptom-free within one day. Thirty-five percent of patients who received ketamine still showed benefits seven days later. Participants receiving a placebo infusion showed no improvement. One week later, participants were given the opposite treatment, unless the beneficial effects of the first treatment were still evident. This "crossover" study design strengthens the validity of the results.

"To my knowledge, this is the first report of any medication or other treatment that results in such a pronounced, rapid, prolonged response with a single dose. These were very treatment-resistant patients," said NIMH Director Thomas R. Insel, M.D.

Ketamine blocks a brain protein called the N-methyl-D-aspartic acid (NMDA) receptor. Previous studies have shown that agents that block the NMDA receptor reduce depression-like behaviors in animals.

NMDA receptors are critical for receiving the signals of glutamate, a brain chemical that enhances the electrical flow among brain cells that is required for normal function. Studies indicate that dysregulation in glutamate could be among the culprits in depression. Using ketamine to block glutamate's actions on the NMDA receptor appears to improve function of another brain receptor — the AMPA receptor — that also helps regulate brain cells' electrical flow.

Scientists think the reason current antidepressant medications take weeks to work is that they act on targets close to the beginning of a series of biochemical reactions that regulate mood. The medications' effects then have to trickle down through the rest of the reactions, which takes time. Scientists theorize that ketamine skips much of this route because its target, the NMDA receptor, is closer to the end of the series of reactions in question.

"This may be a key to developing medications that eliminate the weeks or months patients have to wait for antidepressant treatments to kick in," said lead researcher Carlos A. Zarate Jr., of the NIMH Mood and Anxiety Disorders Program.

The researchers who conducted the study now are zeroing in on other areas of the glutamate system. Specifying which components of the system are affected by compounds such as ketamine may help scientists understand how and why depression occurs, reveal biological markers that may one day aid in diagnosis, and point the way to more precise targets for new medications.

Dr. Zarate was joined in this research by Husseini K. Manji, chief of the NIMH Mood and Anxiety Disorders Program, and colleagues Jaskaran B. Singh, Paul J. Carlson, Nancy E. Brutsche, Rezvan Ameli, David A. Luckenbaugh, and Dennis S. Charney. Read more!

Franklin must repay state $157K - The Daily Advance

By BOB MONTGOMERY
Staff Writer

The area program director for Albemarle Mental Health Center has been ordered to repay the state nearly $157,000 in retirement benefits because the state Treasurer's Office has ruled that Charles Franklin's retirement is "null and void."

The Treasurer's Office said that Franklin — the state's highest paid mental health program director at $474,000 in total compensation — cannot receive retirement pay and his AMHC salary at the same time.

The State Employees Retirement System prohibits retired public workers from drawing their retirement pay if they're still being paid to perform the same job, according to Garry Austin of the Treasurer's Office retirement division.

Austin stated in a July 14 letter to Franklin that he began drawing retirement benefits last July 1, 2005, but remained "continuously employed" as AMHC's director.

"In order for a member's retirement to become effective in any month, the member must render no service at any time during that month," wrote Austin, citing a state statute. "According to the documentation recently made available to us, you did not meet the requirements (to receive retirement pay.) ... Therefore, your retirement benefit will be suspended effective Aug. 1, 2006."

Austin's letter goes on to state that because Franklin's retirement is "null and void" he was not eligible for the $156,980.36 in retirement benefits he received between July 2005 and June 30 of this year.

Franklin, who recently said his retirement pay is not a public matter, declined to comment Wednesday. He deferred questions to AMHC's attorney, John Morrison, who was out of town Wednesday and could not be reached.

Franklin announced his retirement last July 1, 2005, after serving 34 years with the agency. On that same day, he signed a five-year contract with the AMHC Board of Directors to continue performing his duties through a company he created, Nugget Management and Consulting.

As a result of that agreement, Albemarle Mental Health Center's Board of Directors agreed to increase Franklin's annual salary from $231,729 to $289,000. Franklin recently received a 10 percent pay raise after he helped forge an alliance between AMHC and Tideland Mental Health, bringing his annual pay up to $318,000.

Including his retirement pay of $144,595 a year plus a $1,000 monthly car allowance, Franklin stood to receive $474,600 a year in compensation for the next four years.

Unless the Treasurer's Office ruling is changed, Franklin would be ineligible to receive any retirement benefits if he continues in his current capacity at AMHC, Austin's letter states.

"Upon your termination of employment, you may again apply for retirement," Austin said.

Further, Franklin must repay the state for all state benefits received since July 1, 2005.

"You will be contacted by our chief accountant ... concerning a repayment schedule," Austin's letter states.

The AMHC Board of Directors has been supportive of Franklin's compensation package, with board member Richard Johnson of Dare County calling Franklin "the best" in his profession.

Johnson said last week that concerns raised by Pasquotank commissioners about Franklin's generous pay package are politically motivated in an election year. He called Pasquotank's objections "showboating."

Two Pasquotank commissioners who have been the most vocal opponents of Franklin's high pay, Hank Krebs and Marshall Stevenson, said Wednesday they were glad the state Treasurer's Office has ruled Franklin ineligible for retirement pay.

"He ought to be fired," Krebs said of Franklin. "I'm not showboating. Unlike Mr. Johnson from Dare County, I don't think he's worth that much. I don't think he's worth $150,000. As far as I'm concerned, when I have someone mentally ill showing up at my church, he (Franklin) ain't doing his job."

Stevenson said even though the retirement benefits Franklin was receiving are state tax dollars, "we all pay state dollars."

"I think it's a travesty an individual would take money from a taxpayer, as this has happened," Stevenson said. Read more!

Mentally ill inmates to get care via video - Charlotte Observer

Associated Press

COLUMBIA - Prison officials say a new program that allows mentally ill inmates to talk with doctors by video will cut travel costs and staff time while providing emergency help.

But some advocates for the mentally ill said there is no substitute for face-to-face care.

"Unless you're a TV anchor talking to a camera, it's not something that comes naturally," said Dave Almeida, executive director for the state chapter of the National Alliance on Mental Illness. "Telemedicine should be considered if and only if the bottom line is that there is no other way to get people the help they need. It's a start. It's not a substitute."

Inmates at Perry Correctional Institution will be able to talk to their Columbia-based doctor via TV this fall. The prison already is wired for telecommunication, used regularly for parole hearings where inmates talk to the parole board without leaving.

Officials hope to expand the telemedicine project to two other men's prisons and to the women's prison in Greenwood, said Russell Campbell, health services director for the prison system.

They also might use cameras for physical examinations. Arizona already uses such a system to diagnose inmates, he said.

"We think it's going to be hugely successful," Campbell said. "Not only in terms of reducing transportation costs but we think it's going to add to the quality of what we do because physicians will be able to maximize their time."

At least 10 percent of the prison's system's 23,000 inmates are mentally ill, officials say. The agency has only a few staff psychiatrist positions.

Doctors from the University of South Carolina School of Medicine are working with the prison system on the project and are providing some equipment.

John Solomon, mental health services director for the prison system, said using the television monitors will keep psychiatrists from traveling to the maximum-security prison from Columbia, a two-hour drive each way.

The agency spends about $55 million on health care each year, Campbell said, $6 million of it on mental health.

The Greenville County prison has a population of nearly 1,000, with more than 200 inmates with mental illness, officials said. Read more!

Drug injection eases depression quickly - Raleight News/Obsever

Shankar Vedantam, The Washington Post

WASHINGTON - Government researchers announced Monday that they have had striking success in treating depression in a matter of hours, using an experimental injectable drug that acts much more quickly than conventional antidepressants.


The study, based on a small sample, is part of a push by researchers to develop treatments that can bring quick relief to patients with mental disorders. Patients and their doctors report that it often takes weeks or months for most available medications to improve symptoms.

Much more work needs to be done before patients can see benefits from the breakthrough, the researchers said. Among the questions are whether patients will be able to tolerate the drug for long periods and whether it will continue to be effective. Researchers said they hope the finding will prompt the pharmaceutical industry to develop similar compounds with fewer side effects that can then be tested on a large scale.

"Psychiatrists have gotten used to the idea we have to wait weeks or months, but we can break the sound barrier and get an antidepressant effect within hours," said Carlos Zarate Jr., chief of the mood disorders research unit at the National Institute of Mental Health.

Zarate and his colleagues published a paper about their findings Monday in the Archives of General Psychiatry.

In the study, 18 patients were injected with the drug ketamine, which has been used for a long time as an anesthetic. Patients briefly experienced a well-known side effect of the drug -- a mild feeling of dissociation, where they felt disconnected or found it difficult to put thoughts into words.

Ketamine is a controlled substance and can produce mild euphoria.

But the dissociative symptoms disappeared within a couple of hours, and shortly afterward patients and physicians reported a dramatic improvement in mood. Half the patients had a 50 percent decline in depression symptoms, and by the end of the first day, 71 percent reported a similar improvement. More than a third continued to report such a benefit after seven days, and nearly a third reported a complete end of symptoms. Conventional antidepressants approach those kinds of numbers only after eight to 10 weeks of treatment.
Read more!

Agrees CIT would be a benefit to WNC - Asheville Citizen-Times

Letter to the Editor

by Marlene Wooten

published August 9, 2006 12:15 am

I moved to Asheville in February from Charleston, S.C. I have a son who suffers from mental illness. While in Charleston he called 911 several times desperate for help, even once threatening the police.

Thankfully, each incident was handled appropriately with no one being harmed.

The National Alliance on Mental Illnesses (NAMI) is providing Crisis Intervention Training (CIT) to the police departments in the Charleston area and it is helping prevent tragedies like the two that happened recently in Asheville.

I live in fear my son will dial 911 here and I will lose my son. Blaming our brave law enforcement officers will not save lives, but proper training in dealing with a person suffering from a brain disorder can.

Marlene Wooten Read more!

Many mental health reform fears unjustified - Greensboro News & Record

Wednesday, August 9, 2006

The following is a Counterpoint:

By Mike Moseley

I am writing to address several issues raised by the July 16 article, "Mental health overhaul worries many." Although the article clearly stated some of the fears that people have expressed about the changes at the Guilford Center, I believe it did not seek to determine if those fears are justified or address the positive benefit that the changes are designed to achieve.

Many communities in North Carolina have already undergone the changes that are currently happening at the Guilford Center. The change is massive and has not been without challenges, but in many communities consumers and their families are achieving positive benefits: the ability to choose their own providers; greater consumer and family control over the services and supports received; a focus on recovery; and a broader array of services that allow consumers to live where they choose. Consumers in these communities have told me they would fight any effort to return to the old way of business.

The article quotes the Mental Health Association in Greensboro as saying, "When you cut mental health services, problems erupt elsewhere." I agree. However, none of the changes in Guilford should reduce services. The General Assembly's recently passed budget provides more money for services in Guilford County, not less. The article also expresses a mother's concern that she will have to determine for herself which mental health agencies can help her child. It is the responsibility of the Guilford Center staff to continue to provide care coordination. In addition, the article does not mention that the child should continue to receive services from a qualified mental health professional case manager, just not one employed by the Guilford Center.

I will not minimize the hard work of transforming our public mental health system. Change is difficult and fear of change is a common human trait. However, I believe that by concentrating only on people's fears without explaining the purpose behind the changes or trying to determine if those fears are justified is not only a disservice to the hard work and positive changes that have already been accomplished in mental health reform but to your readers as well.

The writer is director, North Carolina Department of Health and Human Services, Division of Mental Health, Developmental Disabilities and Substance Abuse Services Read more!

Value Options hasn't impressed - Durham Herald-Sun

The Herald-Sun Editorial

August 9, 2006 4:57 pm

When it comes to the state's privatization of mental health care management, the temptation is to say, "We told you so."

There were precious few people in Durham who wanted a private company to take over handling mental health authorization for Medicaid patients, affecting thousands of people a year. The function would be much better retained locally, said a chorus of voices, including mental health professionals from the Durham Center, local elected officials and this newspaper. A lawsuit even blocked the takeover temporarily. There seemed no way a distant bureaucracy could manage the nuances of treatment for our fellow Durham residents more efficiently and compassionately than we could.

But that's the way the state Department of Health and Human Services wanted the scenario to play out, and so it did, despite community opposition. As a result, a company named Value Options from Virginia has been handling Medicaid patient review and referrals since Aug. 1. So far, the results have been as bad as predicted.

Holly Horne, a regional director for Alpha Omega Health, a mental health care provider, described her agency's interactions with Value Options as a consumer's worst nightmare:

"First, you can never get anyone to call you back," she said. "Second, their 'first line of defense' customer service workers don't know what they are talking about ?. Getting a straight answer is close to impossible."

Other providers told reporter Gregory Phillips the same sad story of phone calls, faxes and emails unanswered, of uninformed and unresponsive staff.

The frustration on the part of local mental health providers is palpable and understandable. The state fought hard for this change -- one might have thought it would have been more prepared.

But despite the temptation to do so, it's too soon to call the whole thing a failure. We should give Value Options a little more time to get its act together. To its credit, a company spokesman acknowledged the problems, pledged to clear the backlog, and promised that in future, the process will be "seamless."

Now that Value Options is carrying the ball, it needs to make good on those promises sooner rather than later.

Making poor first impression only gives credence to those who believed from the beginning that this was a bad idea. Read more!

Crisis training may some day save a life out of balance - Asheville Citizen-Times

Letter to Editor

by Cynthia L. Zalme
published August 8, 2006 12:15 am


At 15, our son Michael had been diagnosed as bipolar. The night arrived when 19-year-old Mike felt compelled to kill himself. He’d told friends so. They called us and the sheriff’s department. All of us who loved Mike communicated constantly, wondering why we’d heard nothing from the officers other than they were doing all they could.

Three hours later Mike was found dead on the Parkway; gunshot wounds to his chest. After his funeral, we asked about the lack of communication from the officers during that evening. We were horrified to find they’d done nothing to locate Mike, stating “it is not against the law to kill yourself.” In their misguided effort to protect Mike’s friends, us and their officers, they’d chosen inaction – most likely due to fear and ignorance surrounding mental illness.

Crisis Intervention Team training for officers is critical so they have confidence and knowledge. It is too late for Michael, but someone skilled may be able to help another pained soul with a chemical imbalance through the darkness until they can be brought back into the light and into life. Even if death results, then we know, through education and appropriate action, we have done our very best.

Cynthia L. Zalme

Candler

Editor’s note: Zalme’s letter does not refer to the Buncombe County Sheriff’s Read more!

Private mental health company under fire - Durham Herald-Sun

By GREGORY PHILLIPS, The Herald-Sun
August 8, 2006 9:13 pm

DURHAM -- The private company now authorizing mental health care for Medicaid patients across the state just isn't up to the task, local rehabilitation center and group home managers say.

The transition from public to private control, they say, has been full of unreturned calls, lost faxes and incompetence.

Durham County was forced to hand over Medicaid patient review and care authorization to Virginia-based Value Options on Aug. 1.

Since then, anyone providing mental health, developmental disabilities or substance abuse care for Medicaid patients in Durham has to call Value Options to get approval so they'll be reimbursed.

So far, that has been tricky, many say.

"First, you can never get anyone to call you back," said Holly Horne, regional director for Alpha Omega Health, which provides behavioral and residential services. "Second, their 'first line of defense' customer service workers do not know what they are talking about, who to send you to, or what their job is. Getting a straight answer is close to impossible."

Providers across the county tell the same story of repeated calls, e-mails and faxes without response, and generally getting the runaround.

"If you ever get to someone from there, you never get a return call," said Frederick Williams, who runs the Meadows Place group home.

He said he's tried for three weeks to get his calls answered.

"It really impacts the care system, because you're not getting paid for services you've already performed," he said.

A spokesman for Value Options, which authorizes care in 11 states, acknowledged the problems. The company, he said, is working to clear the backlog of requests.

"Volume was higher than we expected," Tom Warburton said. "It's our problem as well as theirs."

The state hired Value Options to authorize care statewide as of June 1 as part of an effort to trim $28 million from North Carolina's mental health budget.

The Durham Center, the local mental health agency that used to authorize Medicaid care, sued the state to retain that power. It contended that private companies wouldn't save money because they'd be more likely to reauthorize expensive services that may not be best for the consumer.

The lawsuit was dropped last month when a change to state law effectively pulled the rug from under it.

Of the more than 8,400 people who received mental health services in Durham County over the last year, 79 percent of the children and 39 percent of adults were Medicaid patients.

Currently, 88 of the 132 providers contracted to provide mental health services in the county are enrolled with Medicaid, and between two and four new providers a month ask to join that number.

Warburton said Value Options is trying to recruit more staff to handle that demand. But he said that could take several months because of industrywide problems finding licensed clinicians.

In the meantime, he said, the company will tweak its technology and use nonmedical staff to handle calls that don't require clinical input. He estimated clearing the current backlog would take two to three weeks.

"There will be bumps in the road, but over time this will come to be a seamless process," he said. "In no way will this backlog translate into reimbursement issues down the road for our provider partners."

Providers sending in incomplete or incorrect request forms because they're not familiar with the company's procedures have added to the backlog, Warburton said.

He said providers elsewhere were trained in that and attributed Durham's "operational shock" to its last-minute addition to the contract.

But some local providers say they sought training months ago and couldn't get it.

"Every time we looked into the trainings they were closed out," said Erica Weaver, membership coordinator for Threshold, a Durham mental health rehabilitation center.

Weaver said she got no answer whenever she tried to find out when the next training would be.

"People are not returning our calls," she said. "They haven't even returned e-mails."

No one at the Division of Medical Assistance, which oversees the state's contract with Value Options, could be reached Tuesday.

But a letter from the Division of Mental Health to local agencies last month said it was "aware of certain challenges and issues." The letter, however, added it is "critical that the provider does not stop services if it has not heard from Value Options."

The letter also assured providers that authorization of care would continue uninterrupted if paperwork was submitted correctly.

But that's been of scant comfort to providers.

"I'm really frustrated," said Denise Ramseur, who runs a group home. "My authorization has run out, but you want me to keep providing services and I don't know if I'm going to be reimbursed. I need to be able to pay my staff, and I can't pay my staff if I can't get reimbursed."

Durham Center administrators, in the midst of trying to restore good relations with the state after their legal battle, would say only that the center's remaining staffers are available to help providers.

But Doug Wright, chairman of the local mental health board, called the transition "a chaotic disaster."

"The state did it the way the state does things, which is haphazard," he said.

Haphazard just isn't good enough for providers.

"I'm not saying it's a bad thing, but they need to manage it properly," Ramseur said. "They fought for this, now handle it." Read more!

Antidepressants prove addictive to some - Associated Press

http://www.chron.com/disp/story.mpl/ap/health/4097903.html

By MATT CRENSON AP National Writer

When Gina O'Brien decided she no longer needed drugs to quell her
anxiety and panic attacks, she followed doctor's orders by slowly
tapering her dose of the antidepressant Paxil. The gradual withdrawal
was supposed to prevent unpleasant symptoms that can result from
stopping antidepressants cold turkey. But it didn't work.

"I felt so sick that I couldn't get off my couch," O'Brien said. "I
couldn't stop crying."

Overwhelmed by nausea and uncontrollable crying, she felt she had no
choice but to start taking the pills again. More than a year later the
Michigan woman still takes Paxil, and expects to be on it for the rest
of her life.

In the almost two decades since Prozac _ the first of the
antidepressants known as SRIs, or serotonin reuptake inhibitors _ hit
the market, a number of patients have reported extreme reactions to
discontinuing the drugs. Two of the best-selling antidepressants _
Effexor and Paxil _ have led to so many complaints that some doctors
avoid prescribing them altogether.

"It's not that we never use it, but in the end I will tend not to
prescribe Effexor or Paxil," said Dr. Richard C. Shelton, a
psychiatrist at the Vanderbilt University School of Medicine. Shelton
has received grant support from the makers of both drugs and consulted
for a number of other pharmaceutical companies.

Patients report experiencing all sorts of symptoms, sometimes within
hours of stopping their medication. They can suffer from flu-like
nausea, muscle aches, uncontrollable crying, dizziness and diarrhea.
Many patients suffer "brain zaps," bizarre and briefly overwhelming
electrical sensations that propagate from the back of the head.

Though not exactly painful, they are briefly disorienting and can be
terrifying to patients who don't know what they are experiencing. There
are case reports of people who have just quit antidepressants showing
up in hospital emergency rooms, thinking they are suffering from
seizures.

Toni Wilson certainly didn't know how unpleasant going off Zoloft could
be when her doctor recently switched her to Wellbutrin, telling her
that the new drug would "take the place of" the old one. The two
antidepressants actually work on entirely different neurochemical
systems, so going straight from one to the other was equivalent to
quitting Zoloft cold turkey.

"After about three days I felt real anxious and irritable," the Kansas
woman said in an e-mail message. "I would shake, not eat much, it felt
like little needles in my body and head."

Cases like Wilson's would be virtually nonexistent if physicians took
more care in weaning their patients off antidepressants, said Philip
Ninan, vice president for neuroscience at Wyeth, the maker of Effexor.

"The management of discontinuation symptoms is relatively easy if you
know about it," Ninan said, and noted that Wyeth had made efforts to
educate both physicians and patients.

Yet surprisingly few doctors know enough about SRI discontinuation to
manage it effectively. A 1997 survey of English doctors found that 28
percent of psychiatrists and 70 percent of general practitioners had no
idea that patients might have problems after discontinuing
antidepressants. Awareness may have increased since then, but the
phenomenon is so little studied that no one has done the necessary
research to find out.

The condition's prevalence is equally mysterious. Studies put the rate
at anywhere from 17 percent to 78 percent for the most problematic
drugs.

So little is known about it that researchers aren't even exactly sure
what causes the symptoms. It may be related to the fact that the brain
chemical affected by most of the antidepressants on the market today,
serotonin, does a lot more than regulate mood. It is also involved in
sleep, balance, digestion and other physiological processes. So when
you throw the brain's serotonin system out of whack, which is
essentially what you're doing by either starting or discontinuing an
antidepressant, virtually the whole body can be affected.

Generally the drugs that are metabolized most quickly cause more severe
symptoms, Shelton said. Effexor, which breaks down in a period of
hours, is one of the worst SRIs in that regard; Prozac, which has a
half-life of about a week, is considered the best.

Some doctors have been able to minimize withdrawal symptoms in patients
who are quitting Effexor or Paxil by gradually switching them over to
Prozac, then tapering them off the more easily discontinued drug.

Critics of the pharmaceutical industry complain that drug companies
downplay the severity of drug discontinuation symptoms. The prescribing
information companies provide to doctors warns that patients
occasionally experience mild symptoms when they stop taking SRI
antidepressants, but imply that tapering off the medication can prevent
problems. Medical journals describe the ill effects of going off the
drugs as "mild and short-lived," and usually avoidable if the dose is
tapered.

"I don't think they're difficult to go off," said Alan Schatzberg,
chairman of the department of psychiatry and behavioral sciences at the
Stanford University School of Medicine. "The vast majority of people
aren't that sensitive."

Schatzberg recently chaired a Wyeth-sponsored panel of physicians that
offered guidelines for how to manage "antidepressant discontinuation
syndrome," the preferred medical term for what a layperson would think
of as withdrawal. He has also served as a consultant to several other
pharmaceutical companies.

Terms like "antidepressant discontinuation syndrome" demonstrate the
pharmaceutical industry's efforts to downplay the problem, charged
Karen Menzies, an attorney who has been involved in litigation over the
phenomenon.

"Withdrawal is the word that is used in Europe," she said.

In December 2004 Britain's drug regulatory agency issued a report that
warned that all SRIs "may be associated with withdrawal" and noted that
Paxil and Effexor "seem to be associated with a greater frequency of
withdrawal reactions."

But drug companies insist antidepressants can't cause withdrawal
because they are not technically addictive. Even so, many patients who
have gone through the experience say it feels like withdrawal to them.
Some can't work, drive, socialize or do other everyday things for
weeks.

"You just feel awful," said a New York children's entertainer, who
asked not to be named for professional reasons. He has taken a small
dose of Effexor for eight years rather than suffer through the
withdrawal experience. But he said the inconvenience is worth it for
the benefits the drug provided him when he needed it.

Taking SRIs indefinitely is not an attractive option for many patients
because it means putting up with unpleasant side-effects such as weight
gain and sexual dysfunction. For women who want to have children it's
an especially risky choice; researchers have documented withdrawal in
newborns whose mothers were taking antidepressants, and some SRIs have
been linked to birth defects.

Having to keep taking Paxil makes O'Brien angry because she feels at
the mercy of GlaxoSmithKline, the company that makes it.

Though a GSK spokesperson said the symptoms associated with
discontinuing Paxil are generally mild and manageable, in O'Brien's
eyes the company is profiting by having hooked her on one of its drugs.

"If they ever did quit making Paxil, I'd be in so much trouble,"
O'Brien said. "What really makes me mad is if I can't get off it, why
am I paying them? They should be paying me." Read more!

Mental health experts look south - Raleigh News & Observer

Modified: Aug 07, 2006 01:35 AM

Mecklenburg County's services offer a convenience some say Wake should adopt

RYAN TEAGUE BECKWITH, Staff Writer

In Wake County, mental health care is like a crowded farmer's market where customers shuffle between dozens of smaller vendors. Unless you know exactly what you need, it can be stressful.

Across the state, Mecklenburg County's system is more like a supermarket, with an array of services conveniently offered under one roof.

The sharp contrast has raised questions about Wake's plans to privatize mental health treatment, required by the state as part of a reform effort that began five years ago.

Local mental health advocates say that the integrated approach in the greater Charlotte area makes more sense than Wake's plans for a patchwork of providers.

"In Mecklenburg, they have focused on one major provider, and that makes it a lot less confusing for customers," said Ann Akland, president of the Wake chapter of the National Alliance on Mental Illness, an advocacy group.

A group of hospital officials, county leaders and advocates from Wake visited Mecklenburg County last week on a fact-finding trip. Several came away with the same critique of Wake's current plans, including some county administrators.

"We have everything they have," said Bob Sorrels, a top official in Wake's human services department. "It's just not all in one place."

The visit came at a crucial time for mental health services. Critics have said that the state's push to privatize treatment is in danger of leaving many patients lost in a confusing marketplace, especially in Wake.

On the same day as the trip to Mecklenburg, the Wake Consumer and Family Advisory Committee, a group of patient advocates, issued a report that criticized the county for not coordinating treatment better.

The nine-page report said that the county and its dozens of private providers do not have "sufficient controls" in place to ensure that patients are "reliably connected to the most appropriate services."

Under the state's reform efforts, Wake County is supposed to turn many of its mental health services over to the private sector -- hospitals and other providers. A major part of that change would be opening a short-term treatment center for people who have had a breakdown.

For the past two years, the county has talked with three local hospitals -- WakeMed, Rex Healthcare and Duke Health Raleigh -- to see if one would be willing to run the planned 60-bed treatment center.

So far, that is all the hospital would do. Smaller contractors would provide other mental health services, and the county would continue to provide a few essential services. Neither the county nor the hospitals are willing to commit to more right now.

County officials say that they wouldn't object to a hospital providing other services, but they didn't want to ask for too much.

For their part, hospital administrators say they appreciate the benefits of an integrated approach, but haven't been asked yet. "I think everybody is really waiting on the county," said Amy Blackwell, a consultant with WakeMed who has worked on the issue.

Similarities, contrasts

With more than 800,000 residents, Mecklenburg County is slightly bigger than Wake, and in other respects the two counties are practically twins. Both are booming urban areas with low unemployment and good medical care.

But their mental health care systems are worlds apart.

No general hospital in Wake currently treats mental illnesses. Only Holly Hill Hospital, a private facility run by a Tennessee-based company, provides short-term treatment, and it does not accept charity cases.

Instead, adults on the federal Medicaid program and the uninsured are sent to the Dorothea Dix state hospital, which is scheduled to close in 2008.

The county has relied heavily on Dix, which is in Raleigh. In the 2006 fiscal year, 44 percent of Dix's patients -- or 2,194 out of 4,962 -- were from Wake County. By comparison, only 12 percent of the patients at the state-run Broughton Hospital in Western North Carolina were from Mecklenburg County, or 460 out of 3,778.

Many Mecklenburg patients go instead to Carolinas HealthCare System. The public health-care system, which has had a contract with Mecklenburg since 1986, has a hand in nearly every phase of treatment. The only exceptions are substance abuse and developmental disabilities.

At an airy complex in Charlotte, Carolinas manages a psychiatric emergency room, short-term inpatient treatment, intensive outpatient care, partial hospitalization, child and adolescent treatment and a medication clinic.

To direct patients to the proper care, it also staffs a 24-hour psychiatric call center.

Hospital officials say that integration of care helps them keep costs down, provide better treatment and prevent at-risk patients from falling through the cracks.

"The doctor can follow patients wherever they are, and that makes a huge difference," said Laura Thomas, vice president of mental health at Carolinas HealthCare.

Mecklenburg County officials say that the arrangement has also reduced the need for more expensive care. The hospital has a financial incentive to keep people with mental illnesses stable through better prevention, because it pays the cost if they have a breakdown.

That wouldn't be the case with Wake's plan.

"If you're only contracted to provide one little piece -- like a short-term treatment center -- your incentive is just to fill those beds," said Grayce Crockett, Mecklenburg's director of mental health services.

The centralization of services means Mecklenburg has fewer providers -- just 71, compared with more than 300 in Wake.

It also means a much larger contract. This year, Mecklenburg's contract with Carolinas HealthCare is worth about $17 million. Wake County has set aside $5 million a year to pay a hospital to run a short-term treatment center, though its overall spending is comparable.

Sometime in the next few weeks, Wake plans to meet with the three general hospitals and Holly Hill to continue negotiations about how the short-term treatment center would be run. In the next meeting, they will discuss the lessons learned in Mecklenburg. "We will continue to look for a collaborative solution," said Deputy County Manager Joe Durham.

Staff writer Ryan Teague Beckwith can be reached at 836-4944 or rbeckwit@newsobserver.com.

Read more!

Mining Prescription Records for Fun and Profit - San Francisco Chronicle

California has become a battleground in a debate over how Big Pharma's access to prescription data affects patient care and the price of drugs

- Jake Whitney

Sunday, August 6, 2006

One afternoon in early 2002, Dr. Brad Drexler, an obstetrician in Healdsburg, got a visit from a pharmaceutical sales representative. The drug rep was from a company called Berlex, and the drug she was selling was Yasmin, a birth control pill that had been on the market for about a year.

Unlike some physicians, Drexler enjoyed visiting with drug reps, and saw them routinely; only in rare instances did he refuse to speak with them. The visit with the Berlex rep that day was typically pleasant. The rep was so friendly, in fact, that she thanked Drexler for all the prescriptions he had been writing for Berlex's pharmaceuticals.

Drexler found the statement odd. He wasn't in the habit of divulging to salespeople how often he prescribed their company's drugs, so he wondered just how the rep knew. Drexler called local pharmacies and asked the pharmacists if they had any knowledge of drug reps gaining access to prescription records. But they were as befuddled as he was.

Then one day, a rep with whom Drexler was particularly friendly spilled the beans. He told Drexler that he and his fellow reps were provided with detailed prescription information, which was stored in their laptops, on every physician in their sales territory.

"It bothered me in two ways," Drexler said. "One, that this practice was so hidden that neither I nor any of the pharmacists I spoke with knew it occurred. And two, because this potentially changed the equation between doctor and drug rep." He added, "I felt like I lost a lot of privacy that day."

The discovery prompted Drexler to take his concerns to the California Medical Association, where he had been a member of its House of Delegates. He introduced a resolution there calling for the CMA to oppose drug company access to prescription records.

Today, three years after Drexler's resolution, California has become a key battleground in a growing debate over how drug companies' access to prescription data affects both patient care and the price of pharmaceuticals. A pilot program, to be launched imminently with 100 doctors, may determine just how easy, or difficult, it will be in the future for pharmaceutical companies to access this information.

Drug companies have been buying prescription records since the 1990s, yet the practice is still not widely known. Even many doctors don't know it occurs.

According to a Kaiser Family Foundation survey taken in 2001, 34 percent of doctors did not know that drug companies had access to their prescription writing history. In 2004, a survey sponsored by the American Medical Association found that number to have shrunk to about 25 percent. And, like Drexler, the more doctors learn of the practice, the more they try to stop it.

The imminent pilot program had its genesis in 2003, when, spurred by physician complaints and encouragement from the CMA, Assemblywoman Wilma Chan, D-Oakland, presented Assembly Bill 262 to the California Legislature. AB 262 would have banned statewide the use of prescription data for marketing purposes.

Despite strong support from the CMA, opposition to Chan's bill was intense. Between its introduction in February 2003 and its demise in August 2004, AB 262 was amended 13 times to mollify various interest groups. Concessions were made allowing prescription data to be collected for research purposes -- the bill's opponents' chief argument as to the benefits of the practice -- but, according to Chan, lobbying from the pharmaceutical industry and data mining companies, especially IMS Health, crushed it.

Data mining companies such as IMS Health play the role of middleman in tracking prescription records. These firms buy records from pharmacy chains and other sources before repackaging them and selling them to drug companies. When pharmacy chains sell the records, however, they do not include patient names and, in some cases, the doctors who wrote the prescriptions. So drug companies turn to a surprising source to complete the prescription profiles: the AMA.

The AMA leases its "physicians' Masterfile" to data mining companies and, through them, subleases it to pharmaceutical companies. This Masterfile contains personal and professional information, including the Drug Enforcement Agency number on all doctors practicing in the United States. And since every prescription written in the United States must include the prescribing physician's DEA number, drug companies use these physician-unique numbers on the Masterfile to match prescription records to doctors.

How important are the profiles to drug reps? "An enormous help," said Kathleen Slattery-Moschkau, whose 2005 film "Side Effects" is loosely based on her 10 years peddling pills for pharmaceutical giants Johnson & Johnson and Bristol-Myers Squibb. "They allow reps to enter doctors' offices armed and dangerous."

Slattery-Moschkau said that when she was a rep she was given reports on every doctor within her sales territory by drug class, as well as "numerous other reports, such as the 'Heavy Hitter List,'" which would include the top physicians her company was trying to "convert."

She said the profiles helped her decide which doctors "were worthy of spending my monthly budgets on for lunches, dinners, days at the spa, etc." Overall, she said, the reports "were a great tool for determining which marketing tactics worked best."

Jamie Reidy, a former Pfizer rep who chronicled his days selling Viagra in his 2005 memoir "Hard Sell," put it bluntly: "Prescription data was our greatest tool in planning our approach to manipulating doctors." But the pharmaceutical industry maintains that prescription profiles are collected primarily for research and for other reasons beneficial to patients.

The Pharmaceutical Research and Manufacturers Association, in an e-mailed statement prepared by Senior Vice President Ken Johnson, said that banning the practice (West Virginia, Arizona, Hawaii and New Hampshire are also considering or have considered legislation to ban or restrict it) "could chill important research that protects and improves public health."

The statement added that the data "can be analyzed by researchers to identify poor prescribing habits," and then cited a study by the Centers for Disease Control and Prevention that used the data to examine antibiotic use to help prevent antibiotic resistance and "reduce unnecessary prescribing." The statement concluded that, "Analyzing prescribing data is another way to make sure patients all over the country receive the best possible care."

The AMA shares this position. Its policy is that the data is collected for research, for locating doctors to participate in clinical trials, to assist in distributing drug samples and in case of a drug recall.

Robert Musacchio, the AMA's vice president of publishing and business services, said that as a general rule his organization has no problem with the data being used for marketing purposes, as long as it is not used to "overtly influence the physician/patient relationship."

But critics point to insider revelations like those of Reidy and Slattery-Moschkau as proof that drug companies use the data precisely in this way: to influence doctors' prescription writing. Drexler said it was just this potentiality that engendered his 2003 resolution. He said his concerns were that visits by drug reps, "could be used to inappropriately reward doctors who were prescribing the company's products."

And that with prescription data in their hands, "the potential existed for reps to influence doctors." When asked whether Drexler's fears were merited, Reidy said yes, that reps "totally reward doctors," but not so it's obvious. He illustrated: "Say Dr. X is prescribing a lot of Zithromax (a Pfizer antibiotic) when he used to prescribe Amoxicillin for similar conditions. If the rep rewards him by giving him gift certificates to Morton's Steakhouse and saying things like, 'Thanks for all the business,' then suddenly Dr. X may feel sleazy and stop writing for Zithromax. On the other hand, he may realize what's going on and start asking the rep for gift certificates to Peter Luger Steakhouse."

Physicians' staffs are also targets, Reidy said, especially nurses. He said that in his case he would take nurses out to happy hour where he would thank them for their help in encouraging Dr. X to prescribe Zithromax. Reidy said this would make the nurses feel as if they were a part of his "team," and they'd "know that if the doctor keeps writing Zithromax they'll be having regular happy hours."

Dr. Sharon Levine, an executive director with Kaiser Permanente, the nation's largest HMO, said that it is because of tactics like these that Kaiser's doctors are prohibited from accepting personal gifts from reps (they are allowed to accept gifts that could benefit their practice -- i.e. they can accept a pen, but not a gift certificate to Morton's), and have never made their prescription records available to drug companies.

Studies support these concerns. A 2000 study published in the European Journal of Clinical Pharmacology, for example, found that increased interaction with drug reps led physicians to prescribe against their patients' best interests. A 2003 study in the American Journal of Bioethics found that when a person accepts a gift, no matter how small, "the obligation to directly reciprocate, whether or not the recipient is conscious of it, tends to influence behavior."

And then there's the cost. Drug companies lay out hefty sums for the profiles. IMS Health, just one of a handful of data mining companies, generated $1.7 billion in revenues last year, $847 million from its "Sales Force Effectiveness Offerings." Critics say pharmaceutical companies should be spending that money seeking new medications. (The major pharmaceutical companies generally spend more than twice as much on marketing as they do on research and development. In 2005, for example, Pfizer spent $17 billion globally on "selling, information and administration" and $7.4 billion on research and development.)

Levine said that the high cost of the profiles manifests itself on drug prices in two ways. Not only is the high cost reflected directly in higher drug prices, but the data is used to persuade doctors to prescribe expensive, brand-name drugs -- often when much cheaper generics would do -- which jacks up co-pays and insurance premiums. Physician privacy is another concern. Dr. Zoe Berna, a family practitioner in Vacaville, is against drug companies gaining access to her records because she thinks she should be free to write prescriptions without salespeople looking over her shoulder. "I definitely feel (drug company access to prescription records) is an invasion of my privacy," she said. Berna added that she would support an outright ban of the release of the data.

In California, at least, that possibility may have died along with AB 262.

But, according to Dr. Jack Lewin, the CMA's chief executive officer, though Chan's bill failed to become law, it initiated almost two years of negotiations among the AMA, IMS Health and the CMA, at the end of which a happy compromise was reached.

Lewin went as far as to assert that the results of the compromise would benefit physicians more so than Chan's bill would have. "We could have gotten (AB 262) passed in any event, except we think we have the better option now," Lewin said in an e-mail.

"The better option" is a new program, unique to the state, built around three main facets.

The primary feature is an "opt out" mechanism that will allow doctors to choose whether or not drug companies may access their physician-specific data.

Second, for those physicians who do not use the "opt out" mechanism, IMS will be required to send them the same data package containing their personal prescription profile it sends to drug companies. In addition, IMS will provide reports comparing the "opting in" physician's prescription patterns with those of area doctors who share the same specialty.

Third, physicians who "opt in" will be e-mailed, on a quarterly basis, an unbiased educational newsletter about the latest medications and developments in their field.

Lewin said that a pilot of the new program is imminent. The statewide rollout is scheduled for January 2007.

The AMA launched its own "opt out" program on July 1. According to Musacchio, the AMA's Physician Data Restriction Program (PDRP) allows physicians to request their individual prescribing data be hidden from pharmaceutical sales representatives -- similar to the California program, but minus the requirements of IMS Health. (In both programs drug companies would continue to have access to aggregated prescription data, including the data of the physicians who have "opted out.")

A spokesperson for IMS Health said in an e-mail that the company supports the AMA's PDRP program, and that the California compromise "will give physicians better insights into their own practices and those of their peers, helping to drive improvements in patient care."

Critics, however, assert that both programs suffer from an inherent flaw: with so many doctors still oblivious to the practice in the first place, the reliance on an "opt out" mechanism is ludicrous -- you can't "opt out" of something you don't know exists.

One of the harshest critics, especially of the AMA's program, is New Hampshire state Rep. Cindy Rosenwald, D-Nashua, who in May pushed a bill through the New Hampshire legislature that would ban statewide the release of prescription data for all commercial purposes. Gov. John Lynch signed the bill June 30, making it the first such legislation in the nation.

Rosenwald said the PDRP program doesn't go nearly as far, and suggested it was simply an effort by the AMA to prevent more bills like hers, and more compromises such as California's. Pointing out that the AMA generates millions of dollars per year with the lease of its Masterfile (the AMA would not comment on how much it made), Rosenwald said, "The AMA has absolutely no incentive to stop the practice."

(Mussachio said that the AMA recognizes that there has been inappropriate use of the data, but there was no need for an outright ban because the PDRP program gives physicians a choice. He added that a lot of younger physicians like being presented with the data because it helps them measure their "performance.")

So what did Drexler think of these "opt out" programs, particularly the California compromise he may have helped engender after an innocent encounter with a birth control rep more than three years ago?

"I still believe drug company access to physician data should be banned," he said, adding that it may be time to "rethink (his) attitude" toward drug reps. He concluded, "but the compromise is a good thing, because it's the best we could get."

New York freelancer Jake Whitney's work has appeared in New York magazine, the Long Island Press and Guernicamag.com.
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Mom posts signs for her slain son - Asheville Citizen-Times

by Adam Behsudi, ABEHSUDI@CITIZEN-TIMES.COM

published August 5, 2006 12:15 am

ASHEVILLE - Every time Tammy Revis gets a little extra money these days, she uses it to make signs in memory of her son, Terry Jackson Evans, who was shot and killed July 13 by a Buncombe County Sheriff's deputy.

The signs, part memorial, part protest, proclaim that Evans was “shot and killed by Buncombe County Sheriff.”

“There's going to be signs up all over Asheville,” she said.

Already, Revis said she's posted about 55 of the signs in West Asheville and Leicester.

She said she hopes to make a statement about the circumstances of her son's death, which she said was unnecessary.

So far, she said she's spent about $200 on signs and banners memorializing her son.

Sheriff Bobby Medford said Friday that Revis is “welcome to put up any signs she wants; she certainly has that right.”

“I hate she feels that way, but nothing I say or do will help her with her grief.”

The night of Evans' death, a deputy responded to a 911 call Revis made saying she feared Evans would take his own life.

After a struggle with her son in which she said she took control of a shotgun he was holding, Revis said the deputy purposely shot Evans.

The Sheriff's Department maintains that the officer feared for his own safety and that the gun had been pointed at him.

“I have to live with knowing that I called 911,” Revis said. “My son was my life.”

Now, she's making the signs, and they're going up as fast as she can get them made.

She also plans to hold a demonstration and vigil for her son today in West Asheville.

The State Bureau of Investigation is investigating the shooting. No information has yet been released.

Henry Ward, Revis' brother, said the family hasn't been updated on anything yet and is

fully behind his sister's sign campaign.

“We're just trying to get the public aware of what actually is going on,” he said. “There's got to be a change.”

But Ward wasn't hopeful about the outcome of the case.

“I feel in my heart that there won't be anyone charged in this,” he said.

Contact Adam Behsudi at 828-232-5962 or via e-mail at abehsudi@ashevill.gannett.com.
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Failed lawsuit, lack of funds lead to Durham Center job cuts - Durham Herald-Sun

BY GREGORY PHILLIPS : The Herald-Sun
gphillips@heraldsun.com
Aug 3, 2006 : 11:20 pm ET

DURHAM -- Its legal war with the state -- and subsequent $832,000 in funding -- lost, Durham County's mental health agency has cut 15 positions, but only eight employees will actually lose their jobs.

Eight of the positions cut from The Durham Center were filled, the other seven were already vacant, according to director Ellen Holliman, who said the cuts would take place by Aug. 31.

The Durham Center had battled to retain the right to review cases and authorize care for Medicaid patients, a job the state handed to Value Options -- a private, out-of-state company -- for local agencies statewide earlier this year. The center sued, alleging violation of state statutes and breach of contract, but state lawmakers changed the statutes last month, effectively pulling the rug out from under the suit.

The center dropped the case. The eight workers to be released come from throughout the center's operations: finance, customer service, contracts, quality management and administration.

"They went across the board of each department," Holliman said.

Holliman said she appreciates the commitment of the staff who stuck with the center through the uncertainty.

"We did not lose one staff member during the up-and-down of the last two years," she said. "I have tremendous gratitude towards the staff that hung in there."

The legislative amendments did preserve the right for local agencies to handle their own after-hours screening of cases, which was also part of the center's suit after the state announced plans for another agency to perform that function for Durham.

Keeping that role allowed the center to avoid cutting two further positions by moving staff to the screening, triage and referral unit, Holliman said.

Doug Wright, chairman of The Durham Center board, said he hopes the new legislation is a sign the state will stop moving the mental health reform goalposts, with additional cuts announced periodically over the last two years as the state sought to cut $28 million from its budget.

"The amendments to state law did help solidify the roles of local management entities," he said. "I do hope our role in the end will be expanded. In the meantime, we'll do the best we can with what we have."

What may happen next remains a mystery to local officials.

"I really don't know," Wright said. "This is politics."

The state had lauded The Durham Center for its embrace of reforms before the local agency sued the state over management of services. In a letter sent to Carmen Hooker Odom, head of the state Department of Health and Human Services after the lawsuit was dropped, Holliman sought to "reach out in good faith" and pledge The Durham Center's commitment to "stay the course for mental health reform."

However, the letter maintained the center's concern over the loss of review and authorization power, with which the center claims it saved money by reducing unnecessary treatment, admissions to state hospitals and out-of-home placements for children served by Medicaid.

"We fear that these gains may be reversed due to the loss of our ability to oversee care," the letter said. Read more!

Violence and Mental Disorders: Data and Public Policy - American Journal of Psychiatry

Paul S. Appelbaum, M.D.

Violence and mental disorders-rightly or wrongly-appear to be irreversibly linked in the popular mind. Articles in this issue of the Journal shed light on two key questions about this relationship:

To what extent do mental disorders confer a greater risk of violent behavior?

What steps may be helpful in reducing the incidence of violence among those who suffer from mental disorders?

Sweden's comprehensive national registers of hospital admissions and criminal convictions provide the data for Fazel and Grann's exploration of the impact of severe mental illness on violent crime in this issue. Linking the two registers, the authors find that persons with psychoses are about four times more likely than the general population to have been convicted of a violent crime but that the psychotic group accounts for just 5% of such offenses. Age, gender, diagnosis, and type of criminal offense all affect the odds ratios for violent convictions and the percentage of crimes attributable to persons with psychoses. Of particular note, women with severe mental illnesses make a negligible contribution to the overall rate of violence.

These Swedish data confirm an evolving consensus on the relationship between serious mental illnesses and violence. Studies using a variety of methods have shown an elevated risk for violence among persons with mental disorders (1). However, the proportion of violence that they account for is relatively small, suggesting that the well-documented public perception of the mentally ill as dangerous persons is substantially exaggerated (2) and that the disproportionate attention given to their acts of violence by the media and by our elected representatives is unwarranted.

It is important to note that the results of Fazel and Grann regarding the percentage of violence attributable to persons with psychoses cannot be extrapolated directly to the American context. In countries such as Sweden, with low rates of violent crime, persons with serious mental illnesses are likely to account for a larger percentage of criminal violence than in countries such as the United States. Nevertheless, the finding of an 18% attributable risk of homicide for people with psychoses in that population, although unlikely to be replicated in the United States, underscores the importance of continuing research on factors that mediate the risk of violence in our patients and on the means of reducing that risk.

How, then, given the current state of our knowledge, ought we to respond to the possibility of violence among persons with mental disorders? Swanson and colleagues explore one approach in this issue. Drawing on a five-site survey of 1,011 outpatients of community mental health centers, they document the extent to which legal mandates and access to money and housing are used to leverage compliance with treatment among persons who report acts of violence or physical aggression. Legal mandates for treatment are significantly more common among persons with histories of more serious violence and among persons with any level of violence who also report poor medication compliance.

Taken at face value, the data of Swanson et al. suggest that when legal mandates are available, they are targeted at patients with elevated risks for violence. (As the authors note, the cross-sectional nature of the data makes it impossible to determine the causal relationship, i.e., to demonstrate that it was violence and not some other factor that led to the imposition of the mandates.) Highly publicized acts of violence by persons with mental disorders often evoke calls for expanded mandatory treatment; outpatient commitment, in particular, has been adopted by a number of states in response to such events. Indeed, an earlier study by some of these authors suggested that outpatient commitment, when paired with frequent clinical contacts, may reduce the subsequent risk of violence (3). From this perspective, the data presented here suggest a rational use of leverage for treatment.

But it remains an open question whether the full panoply of approaches to mandatory treatment-including those imposed by mental health courts, terms of probation and parole, and outpatient commitment orders-is effective in reducing the risk of violence. Among the variables likely to determine effectiveness in a given population are the extent to which violence is linked to psychiatric symptoms, the efficacy of treatment in reducing those symptoms, the availability of treatment, the degree of compliance with treatment (which may relate to how aggressively the mandates are enforced), and the degree to which positive effects carry over after the termination of the mandate. For example, substance abuse and delusional ideation, both frequently proposed as important determinants, have shown inconsistent strength as predictors of violent outcomes across studies, perhaps because of differences in the methods used and the populations studied (4-7). Given the complex interactions among these variables, claims that widespread use of mandatory outpatient treatment will significantly reduce the risk of violence, although very much worth investigating, are decidedly premature. Indeed, at this point, a stronger argument can be made for mandates as a means of improving the treatment of people with serious mental illnesses than as a mechanism for increasing public safety.

Another widely embraced approach to reducing violence by persons with mental disorders involves restriction of their access to firearms. Norris et al., in this issue, provide a comprehensive review of federal and state statutes directed to this end. Although the federal statute defines the minimum criteria to be applied in determining whether someone can purchase a gun, states can enact more restrictive laws. With most states having enacted legislation, there is substantial variation across jurisdictions; some states limit restrictions to persons who have been involuntarily committed for treatment of mental disorders or convicted of substance abuse-related offenses, whereas others appear to encompass a much broader range of persons who have sought treatment for mental disorders, including substance abuse.

These statutes pose a dilemma for advocates for persons with mental disorders, including psychiatrists and their national organizations. Many such persons and groups are probably appalled at the ready access to firearms that prevails in much of the United States and would favor greater restrictions for all people. Thus, it is difficult for them to oppose any law that makes it harder to acquire a gun. But given that only a tiny fraction of violence, including gun violence, is perpetrated by persons with mental disorders, efforts that center disproportionately on restricting their access reflect a deeply irrational public policy. Moreover, by once more linking mental disorders and violence in the public mind, these firearms laws reinforce the stigmatization of persons with mental disorders as inherently dangerous.

Compounding concern about the effects of these statutes, many of them call for the creation of data banks that accumulate information about persons who meet the criteria for exclusion (e.g., patients who have been involuntarily committed to a psychiatric facility) that can be accessed by one or another state agency before the sale of a firearm. The threat to the confidentiality of psychiatric treatment is evident, and in many cases, it continues indefinitely. Like clinical interventions, public policy initiatives should be subject to evaluations of their effectiveness and adverse consequences. Whether singling out persons with mental disorders, including substance abuse problems, for restrictions with regard to gun purchases is an effective means of protecting the public cries out for careful assessment.

The relationship between mental disorders and violence is complex. Among the variables that have been identified as increasing the risk of violence, in addition to psychotic symptoms and substance abuse, are socioeconomic status and even the neighborhoods in which persons with mental disorders reside. No single approach to reducing the risk is likely to be completely effective. And given the relatively modest contribution to the overall risk of violence by persons with mental disorders, the likelihood and magnitude of adverse effects from any intervention must be carefully considered before it is embodied in law.

Psychiatrists and organizations such as APA have an important role to play as the "honest brokers" in this process. When passions become inflamed by tragic acts of violence, we should be clear voices of factual information and advocates of reason. Real risks should be acknowledged and appropriate interventions endorsed, while distortions are exposed and recourse to discriminatory and stigmatizing policies is discouraged; a tall order perhaps in what is often a politically charged environment, but not a bad set of aspirations.
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Five per cent of violent crimes attributed to severely mentally ill patients - American Journal of Psychiatry

01 August 2006

Am J Psychiatry 2006; 163: 1397-1403

People with severe mental illnesses are responsible for just one in 20 violent crimes, reveal findings published in the American Journal of Psychiatry.

In their study of violent crimes over a 13-year period, Seena Fazel (University of Oxford, UK) and Martin Grann (Karolinska Institute, Stockholm, Sweden) found that 45 violent crimes were committed per 1000 inhabitants, of which 2.4 were attributable to patients with severe mental illness.

This corresponded to a population-attributable risk fraction of these patients to violent crime of 5.2%.

Seena Fazel said that this figure is likely to be lower than most people would imagine.

"Many see those with serious psychiatric disorders as significantly contributing to the amount of violent crime in society," she noted.

The researchers linked data for 98,082 individuals discharged from hospital with diagnoses of schizophrenia and other psychoses to the crime register. The attributable risk was calculated by gender, across three age bands (15-24, 25-39 years, and 40 years and older), and offense type.

Violent offending in women was more attributable to mental illness than in men across the three age bands, at 14.0% in women aged between 25 and 39 years, and 19.0% in those aged over 40 years. Overall, the risk attributed to mental illness was lowest in those aged 15 to 34 years, at 2.3% for male patients and 2.9% for female patients.

The highest risk of violent crime among people with severe mental illness was found for homicide and attempted homicide, and arson, at 18.2% and 15.7%, respectively.

"Because these are higher-profile crimes, this would partly explain the impression given by the media of the high rates of violence in psychiatric patients," the researchers comment.

"However, focusing solely on such crimes would not give a complete picture of the public health burden of violence because the base rates are so low, accountable for only 0.6% of the violent crimes in Sweden in the case of homicide and attempted homicide."

The researchers conclude that their findings "should generate a more informed debate on the contribution of persons with severe mental illness to societal violence."
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Violence and Leveraged Community Treatment for Persons With Mental Disorders - American Journal of Psychiatry

Over the past two decades, the debate over involuntary psychiatric intervention has followed the path of deinstitutionalization into the realm of community-based treatment. In that context, arguments about coercion and violence have become intertwined... .

Most of the controversy over involuntary treatment in the community has focused on outpatient commitment, where the issue of violence appears in several roles. Attitudinal surveys reliably document the popular belief that mental illness causes violence and the strong correlation of this belief with the public’s endorsement of policies that restrict the liberties of, or allow coercion of, persons with mental disorders.

Click here to access the rest of this article,a lengthy, technical article co-authored by Duke Unviversity's Marvin Swartz. Read more!