Why We Need to Abandon the Disease-Model of Mental Health Care

By Peter Kinderman
Scientific American Blog
Originally published on November 17, 2014

Here is an excerpt:

Some neuroscientists have asserted that all emotional distress can ultimately be explained in terms of the functioning of our neural synapses and their neurotransmitter signalers. But this logic applies to all human behavior and every human emotion and it doesn’t differentiate between distress — explained as a product of chemical “imbalances” — and “normal” emotions. Moreover, while it is clear that medication (like many other substances, including drugs and alcohol) has an effect on our neurotransmitters, and therefore on our emotions and behavior, this is a long way from supporting the idea that distressing experiences are caused by imbalances in those neurotransmitters.

Many people continue to assume that serious problems such as hallucinations and delusional beliefs are quintessentially biological in origin, but we now have considerable evidence that traumatic childhood experiences (poverty, abuse, etc.) are associated with later psychotic experiences. There is an almost knee-jerk assumption that suicide, for instance, is a consequence of an underlying illness, explicable only in biological terms.

The entire blog post is here.

Why Doctors need Stories

By Peter D. Kramer
The New York Times
Originally published October 18, 2014

Here is an excerpt:

I have long felt isolated in this position, embracing stories, which is why I warm to the possibility that the vignette is making a comeback. This summer, Oxford University Press began publishing a journal devoted to case reports. And this month, in an unusual move, the New England Journal of Medicine, the field’s bellwether, opened an issue with a case history involving a troubled mother, daughter and grandson. The contributors write: “Data are important, of course, but numbers sometimes imply an order to what is happening that can be misleading. Stories are better at capturing a different type of ‘big picture.’ ”

Stories capture small pictures, too. I’m thinking of the anxious older man given Zoloft. That narrative has power.

The entire article is here.

Prisons are Unable to Afford New Effective Hep C Medication

Prisoners Unlikely to Benefit from New, Highly Effective Hepatitis C Treatment
Prison Legal News
Originally posted July 9, 2014

by Greg Dober

Hepatitis C (HCV) is a blood-borne virus that is typically spread through intravenous drug use (i.e., sharing needles), tattooing with non-sterile needles, and sharing razors, toothbrushes, nail clippers or other hygiene items that may be exposed to blood. It is often a chronic disease and, if left untreated, can lead to severe liver damage.

Recent good news in the battle against HCV, in the form of two new drugs that are highly effective in eliminating the virus, is tempered by the fact that the companies that produce the drugs have priced them at $60,000 to $80,000 per 12-week course of treatment. This high cost prices the medications beyond the reach of most prison and jail systems – which is especially troubling considering that a substantial number of prisoners are infected with HCV.

The entire article is here.

Hospice and Access to Medications - New CMS Guidance

Center for Medicare Advocacy
Originally posted April 10, 2014

Here are some excerpts:

Summary

Medications that should be covered by the Medicare Hospice Benefit are sometimes paid for by the insurance companies that administer Medicare Part D plans.  To prevent this from happening, effective May 1, 2014, all prescribed medications for hospice patients billed to Medicare Part D will initially be denied coverage.  To get their medications, hospice patients will have to initiate and ultimately succeed at a Medicare appeal.  In other words, to protect insurance companies, dying patients will have to jump through hoops to get medically necessary, potentially life-sustaining medications.

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Conclusion

This burden-shifting to the dying patient is illogical and immoral.

CMS has erred in assuming that most hospice patients will not continue to have Part D covered medications.  Most older Americans are on medications for chronic conditions, and some of these medications...

The entire article is here.

Thanks to Deborah Derrickson Kossmann for this information.

Is the Doctor-Patient Relationship Turning Into a Business Partnership?

Reports say patients are increasingly asking doctors for drugs by name, and docs are complying. If they don’t write the script, they risk a low rating on one of many doc-ranking sites.

By Russell Saunders
The Daily Beast
Originally posted April 11, 2014

“The customer is always right.” We all know the saying. It’s a truism in business. Businesses need happy customers. Happy customers keep coming back and they tell their friends. Keeping the customer happy is a businessperson’s number one priority.

Except when the business is a medical practice, and the customer is a patient.

That ever-blurring line between patient and customer is one of the most difficult things to walk in medical practice. On the one hand, people need to keep coming through the door in order to keep it open in the first place, and making sure people have a good experience when they come to you for care is important.

The entire article is here.

Episode 2: Prescriptive Authority for Psychologists - Where are we now?

Bob McGrath

In this episode, John speaks with Robert McGrath, Ph.D.  Bob is a psychologist and Director of the Masters in Science Program in Clinical Psychopharmacology at Fairleigh Dickinson in New Jersey.  He is a tireless advocate of RxP for psychologists.  John and Bob discuss the prescriptive authority movement as well as the benefits of a prescribing psychologists. Training issues, legislative advocacy, and the two states that granted psychologists prescriptive authority will be addressed.

At the end of the podcast, the listener will be able to:

1. Describe two reasons why psychologists are seeking prescriptive authority;
2. Explain two benefits for patients who work with a prescribing psychologist; and,
3. Name two states that permit appropriately trained psychologists to prescribe  
      medication.

Click here to purchase 1 APA-approved Continuing Education credit

Find this podcast in iTunes

Or listen directly on this page

 


Resources

Fairleigh Dickinson Masters Degree in Psychopharmacology

Contact Bob McGrath via email

Prescriptive Authority for Psychologists: Issues and Considerations
Lynn Merrick, Legislative Reference Bureau, State Capitol, Honolulu, Hawaii 96813

Prescriptive Authority for Psychologists
Bob McGrath

APA Resources

Designation Criteria for Education and Training Programs in Preparation for Prescriptive 
Authority (2009)

Division 55 Home Page - American Society for the Advancement of Pharmacotherapy

Model Legislation

Prescriptive Authority Page

Inappropriateness of Medication Prescriptions to Elderly Patients in the Primary Care Setting

Dedan Opondo, Saied Eslami, Stefan Visscher, Sophia E. de Rooij, Robert Verheij, Joke C. Korevaar, Ameen Abu-Hanna
Published: August 22, 2012DOI: 10.1371/journal.pone.0043617

Abstract

Background

Inappropriate medication prescription is a common cause of preventable adverse drug events among elderly persons in the primary care setting.

Objective

The aim of this systematic review is to quantify the extent of inappropriate prescription to elderly persons in the primary care setting.

Methods

We systematically searched Ovid-Medline and Ovid-EMBASE from 1950 and 1980 respectively to March 2012. Two independent reviewers screened and selected primary studies published in English that measured (in)appropriate medication prescription among elderly persons (>65 years) in the primary care setting. We extracted data sources, instruments for assessing medication prescription appropriateness, and the rate of inappropriate medication prescriptions. We grouped the reported individual medications according to the Anatomical Therapeutic and Chemical (ATC) classification and compared the median rate of inappropriate medication prescription and its range within each therapeutic class.

Results

We included 19 studies, 14 of which used the Beers criteria as the instrument for assessing appropriateness of prescriptions. The median rate of inappropriate medication prescriptions (IMP) was 20.5% [IQR 18.1 to 25.6%.]. Medications with largest median rate of inappropriate medication prescriptions were propoxyphene 4.52(0.10–23.30)%, doxazosin 3.96 (0.32 15.70)%, diphenhydramine 3.30(0.02–4.40)% and amitriptiline 3.20 (0.05–20.5)% in a decreasing order of IMP rate. Available studies described unequal sets of medications and different measurement tools to estimate the overall prevalence of inappropriate prescription.

Conclusions

Approximately one in five prescriptions to elderly persons in primary care is inappropropriate despite the attention that has been directed to quality of prescription. Diphenhydramine and amitriptiline are the most common inappropriately prescribed medications with high risk adverse events while propoxyphene and doxazoxin are the most commonly prescribed medications with low risk adverse events. These medications are good candidates for being targeted for improvement e.g. by computerized clinical decision support.

The entire article is here.

Are mental illnesses real? (Part One)

John Danaher
Philosophical Disquisitions
Originally published November 12, 2013

Here are some excerpts:

It may be a push, but I think it is fair to say that no branch of modern medicine faces the same existential challenges as psychiatry. To give a sense of the problem, a quick browse through Amazon reveals a plethora of books, many published within the past ten years, that either directly challenge the legitimacy of mental illness, call into question the medicalisation of the mind, or dispute the unholy alliance between “pharma” and psychiatry. This is to say nothing of the organisations and religious groups (most famously the scientologists) who critique modern psychiatry and try to dismantle its apparatuses.

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Part of the reason for this is philosophical. The attempt to identify, diagnose and treat mental illness seems to bring the mind within the scope of biomedical science: to “reduce” mental phenomena to scientifically tractable, manipulable and treatable “disorders”. This cuts to the core of one of the central projects in modern philosophy: the reconciliation project. This project tries to determine the appropriate relationship between the world as it seems to be to us (the manifest image) and the world as it seems to be when viewed through the lens of modern science (the scientific image).

As such, the topic of mental illness — what it is and how it should be treated — is one that is particularly ripe for philosophical analysis and debate. The purpose of this series of posts is to look at some aspects of this analysis and debate. Specifically, to look at various attempts to determine what an “illness” or “disease” really is, and at arguments for or against the legitimacy of “mental illness”.

The entire blog post is here.

Mental illness: is chemical imbalance theory a myth?

Torstar News Service
Originally published on October 19, 2013

Here is an excerpt:

Now, neuroscience would attribute such things as depression and psychosis to “chemical imbalances” — specifically to disruptions in the neurotransmitters that allow the brain’s billions upon billions of grey matter cells to speak to one another.

And so mental illnesses became normalized and destigmatized.

And so their treatments, to a huge extent, came off of the couch, out of the asylums and onto pharmacy counters.

And so a $70-billion drug market grew to feed tens of millions worldwide with daily doses of magic bullets — pills that could bring their brain chemistry back into balance.

Trouble is, in the minds of many neuroscientists today, that chemical imbalance theory has turned out to be a myth, with little more scientific or medicinal substance than poetry or song.

The entire article is here.

Thanks to Ned Jenny for this information.

Psychotherapy’s Image Problem

By BRANDON A. GAUDIANO
The New York Times- Op Ed
Published: September 29, 2013

PSYCHOTHERAPY is in decline. In the United States, from 1998 to 2007, the number of patients in outpatient mental health facilities receiving psychotherapy alone fell by 34 percent, while the number receiving medication alone increased by 23 percent.

This is not necessarily for a lack of interest. A recent analysis of 33 studies found that patients expressed a three-times-greater preference for psychotherapy over medications.

The entire story is here

APA releases guidelines on cutting antipsychotic overuse

By  Brie Zeltner
The Cleveland Plain Dealer
Originally published on September 20, 2013

Doctors and patients should question of the use of antipsychotic medications in patients, particularly among the elderly with dementia and children and adolescents without psychotic disorders.

That’s according to a list of five common uses of the medications that are potentially unnecessary and could cause harm released today by the American Psychiatric Association as part of a national effort called the Choosing Wisely campaign.

The entire article is here.

A Dry Pipeline for Psychiatric Drugs

By RICHARD A. FRIEDMAN, M.D.
The New York Times
Published: August 19, 2013

Fully 1 in 5 Americans take at least one psychiatric medication. Yet when it comes to mental health, we are facing a crisis in drug innovation.

Sure, we have many antidepressants, antipsychotics, hypnotic medications and the like. But their popularity masks two serious problems.

First, each of these drug classes is filled with “me too” drugs, which are essentially just copies of one another; we have six S.S.R.I. antidepressants that essentially do the same thing, and likewise for the 10 new atypical antipsychotic drugs.

Second, the available drugs leave a lot to be desired: patients with illnesses like schizophrenia, major depression and bipolar disorder often fail to respond adequately to these medications or cannot tolerate their side effects.

The entire story is here.

A Glut of Antidepressants

By RONI CARYN RABIN
The New York Times
Originally published August 12, 2013

Over the past two decades, the use of antidepressants has skyrocketed. One in 10 Americans now takes an antidepressant medication; among women in their 40s and 50s, the figure is one in four.

Experts have offered numerous reasons. Depression is common, and economic struggles have added to our stress and anxiety. Television ads promote antidepressants, and insurance plans usually cover them, even while limiting talk therapy. But a recent study suggests another explanation: that the condition is being overdiagnosed on a remarkable scale.

(cut)

Elderly patients were most likely to be misdiagnosed, the latest study found. Six out of seven patients age 65 and older who had been given a diagnosis of depression did not fit the criteria. More educated patients and those in poor health were less likely to receive an inaccurate diagnosis.

The entire article is here.

Introducing deprescribing into culture of medication

By Catherine Cross
Canadian Medical Association
Originally published August 12, 2013

An Ontario pharmacist has received a government grant to develop clinical guidelines to help doctors determine whether patients are on medications they no longer need or that should be reduced.

"We don't normally test drugs in the elderly, but they are taking many drugs. As they get older and get more chronic conditions, the number of medications increases," says Barbara Farrell, a clinical scientist with the Bruyère Research Institute in Ottawa, Ontario.

Sometimes when medications are deprescribed or reduced, "confusion will clear, or they'll stop falling, and a lot of literature supports that," says Farrell, who received the $430 000 grant from the Ontario Ministry of Health and Long-Term Care.

The entire story is here.

Not robots: children's perspectives on authenticity, moral agency and stimulant drug treatments

By Ilina Singh
J Med Ethics 2013;39:359-366 doi:10.1136/medethics-2011-100224

Abstract

In this article, I examine children's reported experiences with stimulant drug treatments for attention deficit hyperactivity disorder in light of bioethical arguments about the potential threats of psychotropic drugs to authenticity and moral agency. Drawing on a study that involved over 150 families in the USA and the UK, I show that children are able to report threats to authenticity, but that the majority of children are not concerned with such threats. On balance, children report that stimulants improve their capacity for moral agency, and they associate this capacity with an ability to meet normative expectations. I argue that although under certain conditions stimulant drug treatment may increase the risk of a threat to authenticity, there are ways to minimise this risk and to maximise the benefits of stimulant drug treatment. Medical professionals in particular should help children to flourish with stimulant drug treatments, in good and in bad conditions.

The entire article is here.

Dangers found in lack of safety oversight for Medicare drug benefit

By Tracy Weber, Charles Ornstein and Jennifer LaFleur
ProPublica
Originally published: May 11, 2013

Here is an excerpt:

But an investigation by ProPublica has found the program, in its drive to get drugs into patients’ hands, has failed to properly monitor safety. An analysis of four years of Medicare prescription records shows that some doctors and other health professionals across the country prescribe large quantities of drugs that are potentially harmful, disorienting or addictive for their patients. Federal officials have done little to detect or deter these hazardous prescribing patterns.

Searches through hundreds of millions of records turned up physicians such as the Miami psychiatrist who has given hundreds of elderly dementia patients the same antipsychotic, despite the government’s most serious “black box” warning that it increases the risk of death. He believes he has no other options.

Some doctors are using drugs in unapproved ways that may be unsafe or ineffective, records showed. An Oklahoma psychiatrist regularly prescribes the Alzheimer’s drug Namenda for autism patients as young as 12; he says he thinks it calms them. Autism experts said there is scant scientific support for this practice.

The entire article is here.

Why the Fuss Over the D.S.M.-5?

By Sally Satel
The New York Times - Opinion
Originally published on May 11, 2013

LATER this month, the American Psychiatric Association will unveil the fifth edition of its handbook of diagnoses, the Diagnostic and Statistical Manual of Mental Disorders. Fourteen years in the making, the D.S.M.-5 has been the subject of seemingly endless discussion.
      

The charges are familiar: the manual medicalizes garden-variety distress, leads doctors to prescribe unnecessary medications, serves as a cash cow for the association, and so forth.

      

But many critics overlook a surprising fact about the new D.S.M.: how little attention practicing psychiatrists will give to it.

      

There are dozens of revisions in the D.S.M. — among them, the elimination of a “bereavement exclusion” from major depressive disorder and the creation of binge eating disorder — but they won’t alter clinical practice much, if at all.

      

This is because psychiatrists tend to treat according to symptoms.

      

So why the fuss over D.S.M.-5? Because of the unwarranted clout that its diagnoses carry with the rest of society: They are the passports to insurance coverage, the keys to special educational and behavioral services in school and the tickets to disability benefits.

      

This is a problem because the D.S.M. is an imperfect guide to predicting what treatments will benefit patients most — a reality tied to the fact that psychiatric diagnoses are based on clinical appearances that tend to cluster, not on the mechanism behind the illness, as is the case with, say, bacterial pneumonia.

The entire article is here.

Most Docs Don't Follow ADHD Treatment Guidelines for Preschoolers: Study

By Robert Preidt
MedicineNet.com
Originally published on May 4, 2013

About 90 percent of pediatric specialists who diagnose and manage attention-deficit/hyperactivity disorder (ADHD) in preschool children do not follow treatment guidelines published recently by the American Academy of Pediatrics, according to a new study.

Some prescribe medications too soon, while others do not give the young patients drugs even as a second-line treatment, according to study author Dr. Andrew Adesman, chief of developmental and behavioral pediatrics at Cohen Children's Medical Center in New Hyde Park, N.Y., and colleagues.

The American Academy of Pediatrics (AAP) guidelines recommend that behavior therapy be the first treatment approach for preschoolers with ADHD, and that treatment with medication should be used only when behavior-management counseling is unsuccessful.  (Emphasis added)

The entire story is here.

Click here to review the guidelines.

A similar story can be found in Time.

The Problem With How We Treat Bipolar Disorder

By Linda Logan
The New York Times
Originally published on April 26, 2013

The last time I saw my old self, I was 27 years old and living in Boston. I was doing well in graduate school, had a tight circle of friends and was a prolific creative writer. Married to my high-school sweetheart, I had just had my first child. Back then, my best times were twirling my baby girl under the gloaming sky on a Florida beach and flopping on the bed with my husband — feet propped against the wall — and talking. The future seemed wide open.

I don’t think there is a particular point at which I can say I became depressed. My illness was insidious, gradual and inexorable. I had a preview of depression in high school, when I spent a couple of years wearing all black, rimming my eyes in kohl and sliding against the walls in the hallways, hoping that no one would notice me. But back then I didn’t think it was a very serious problem.

The hormonal chaos of having three children in five years, the pressure of working on a Ph.D. dissertation and a genetic predisposition for a mood disorder took me to a place of darkness I hadn’t experienced before. Of course, I didn’t recognize that right away. Denial is a gauze; willful denial, an opiate. Everyone seemed in league with my delusion. I was just overwhelmed, my family would say. I should get more help with the kids, put off my Ph.D.

The entire story is here.

Diagnosis: Human

By Ted Gup
The New York Times Op-Ed
Originally published on April 2, 2013

Here are some excerpts:

No one made him take the heroin and alcohol, and yet I cannot help but hold myself and others to account. I had unknowingly colluded with a system that devalues talking therapy and rushes to medicate, inadvertently sending a message that self-medication, too, is perfectly acceptable.

My son was no angel (though he was to us) and he was known to trade in Adderall, to create a submarket in the drug among his classmates who were themselves all too eager to get their hands on it. What he did cannot be excused, but it should be understood. What he did was to create a market that perfectly mirrored the society in which he grew up, a culture where Big Pharma itself prospers from the off-label uses of drugs, often not tested in children and not approved for the many uses to which they are put.

And so a generation of students, raised in an environment that encourages medication, are emulating the professionals by using drugs in the classroom as performance enhancers.

And we wonder why it is that they use drugs with such abandon. As all parents learn — at times to their chagrin — our children go to school not only in the classroom but also at home, and the culture they construct for themselves as teenagers and young adults is but a tiny village imitating that to which they were introduced as children.

The issue of permissive drug use and over-diagnosis goes well beyond hyperactivity. In May, the American Psychiatric Association will publish its D.S.M. 5, the Diagnostic and Statistical Manual of Mental Disorders. It is called the bible of the profession. Its latest iteration, like those before, is not merely a window on the profession but on the culture it serves, both reflecting and shaping societal norms. (For instance, until the 1970s, it categorized homosexuality as a mental illness.)

The entire story is here.