CA’s Tax On Millionaires Yields Big Benefits For People With Mental Illness

Anna Gorman
Kaiser Health News
Originally published March 14, 2018

A statewide tax on the wealthy has significantly boosted mental health programs in California’s largest county, helping to reduce homelessness, incarceration and hospitalization, according to a report released Tuesday.

Revenue from the tax, the result of a statewide initiative passed in 2004, also expanded access to therapy and case management to almost 130,000 people up to age 25 in Los Angeles County, according to the report by the Rand Corp. Many were poor and from minority communities, the researchers said.

“Our results are encouraging about the impact these programs are having,” said Scott Ashwood, one of the authors and an associate policy researcher at Rand. “Overall we are seeing that these services are reaching a vulnerable population that needs them.”

The positive findings came just a few weeks after a critical state audit accused California counties of hoarding the mental health money — and the state of failing to ensure that the money was being spent. The February audit said that the California Department of Health Care Services allowed local mental health departments to accumulate $231 million in unspent funds by the end of the 2015-16 fiscal year — which should have been returned to the state because it was not spent in the allowed time frame.

Proposition 63, now known as the Mental Health Services Act, imposed a 1 percent tax on people who earn more than $1 million annually to pay for expanded mental health care in California. The measure raises about $2 billion each year for such services, such as preventing mental illness from progressing, reducing stigma and improving treatment. Altogether, counties have received $16.53 billion.

The information is here.

Health Insurers Are Still Skimping On Mental Health Coverage

Jenny Gold
Kaiser Health News/NPR
Originally published November 30, 2017

It has been nearly a decade since Congress passed the Mental Health Parity And Addiction Equity Act, with its promise to make mental health and substance abuse treatment just as easy to get as care for any other condition. Yet today, amid an opioid epidemic and a spike in the suicide rate, patients are still struggling to get access to treatment.

That is the conclusion of a national study published Thursday by Milliman, a risk management and health care consulting company. The report was released by a coalition of mental health and addiction advocacy organizations.

Among the findings:

• In 2015, behavioral care was four to six times more likely to be provided out-of-network than medical or surgical care.


• Insurers paid primary care providers 20 percent more for the same types of care than they paid addiction and mental health care specialists, including psychiatrists.


• State statistics vary widely. In New Jersey, 45 percent of office visits for behavioral health care were out-of-network. In Washington, D.C., it was 63 percent.

The researchers at Milliman examined two large national databases containing medical claim records from major insurers for PPOs — preferred provider organizations — covering nearly 42 million Americans in all 50 states and D.C. from 2013 to 2015.

The article is here.

Artificial Intelligence & Mental Health

Smriti Joshi
Chatbot News Daily
Originally posted

Here is an excerpt:

There are many barriers to getting quality mental healthcare, from searching for a provider who practices in a user's geographical location to screening multiple potential therapists in order to find someone you feel comfortable speaking with. The stigma associated with seeking mental health treatment often leaves people silently suffering from a psychological issue. These barriers stop many people from finding help and AI is being looked at a potential tool to bridge this gap between service providers and service users.

Imagine how many people would be benefitted if artificial intelligence could bring quality and affordable mental health support to anyone with an internet connection. A psychiatrist or psychologist examines a person’s tone, word choice, and the length of a phrase etc and these are all crucial cues to understanding what’s going on in someone’s mind. Machine learning is now being applied by researchers to diagnose people with mental disorders. Harvard University and University of Vermont researchers are working on integrating machine learning tools and Instagram to improve depression screening. Using color analysis, metadata, and algorithmic face detection, they were able to reach 70 percent accuracy in detecting signs of depression. The research wing at IBM is using transcripts and audio from psychiatric interviews, coupled with machine learning techniques, to find patterns in speech to help clinicians accurately predict and monitor psychosis, schizophrenia, mania, and depression. A research, led by John Pestian, a professor at Cincinnati Children’s Hospital Medical Centre showed that machine learning is up to 93 percent accurate in identifying a suicidal person.

The post is here.

Physician licensing laws keep doctors from seeking care

Bab Nellis
Mayo Clinic New Network

Despite growing problems with psychological distress, many physicians avoid seeking mental health treatment due to concern for their license. Mayo Clinic research shows that licensing requirements in many states include questions about past mental health treatments or diagnoses, with the implication that they may limit a doctor's right to practice medicine. The findings appear today in Mayo Clinic Proceedings.

“Clearly, in some states, the questions physicians are required to answer to obtain or renew their license are keeping them from seeking the help they need to recover from burnout and other  emotional or mental health issues,” says Liselotte Dyrbye, M.D., a Mayo Clinic physician and first author of the article.

The researchers examined the licensing documents for physicians in all 50 states and Washington, D.C., and renewal applications from 48 states. They also collected data in a national survey of more than 5,800 physicians, including attitudes about seeking mental health care.

Nearly 40 percent of respondents said they would hesitate in seeking professional help for a mental health condition because they feared doing so could have negative impacts on their medical license.

The article is here.

The target article is here.

The consent dilemma

Elyn Saks
Politico - The Agenda
Originally published August 9, 2017

Patient consent is an important principle in medicine, but when it comes to mental illness, things get complicated. Other diseases don’t affect a patient’s cognition the way a mental illness can. When the organ with the disease is a patient’s brain, how can it be trusted to make decisions?

That’s one reason that, historically, psychiatric patients were given very little authority to make decisions about their own care. Mental illness and incompetence were considered the same thing. People could be hospitalized and treated against their will if they were considered mentally ill and “in need of treatment.” The presumption was that people with mental illness—essentially by definition—lacked the ability to appreciate their own need for treatment.

In the 1970s, the situation began to change. First, the U.S. Supreme Court ruled that a patient could be hospitalized against his will only if he were dangerous to himself or others, or “gravely disabled,” a decision that led to the de-institutionalization of most mental health care. Second, anti-psychotic medications came into wide use, effectively handing patients the power—on a daily basis—to decide whether to consent to treatment or not, simply by deciding whether or not to take their pills.

The article is here.

Nonvoluntary Psychiatric Treatment Is Distinct From Involuntary Psychiatric Treatment

Dominic A. Sisti
JAMA. Published online August 24, 2017

Some of the most ethically challenging cases in mental health care involve providing treatment to individuals who refuse that treatment. Sometimes when persons with mental illness become unsafe to themselves or others, they must be taken, despite their outward and often vigorous refusal, to an emergency department or psychiatric hospital to receive treatment, such as stabilizing psychotropic medication. On occasion, to provide medical care over objection, a patient must be physically restrained.

The modifier “involuntary” is generally used to describe these cases. For example, it is said that a patient has been involuntarily hospitalized or is receiving involuntary medication ostensibly because the patient did not consent and was forced or strongly coerced into treatment. Importantly, a person may be involuntarily hospitalized but retain the right to refuse treatment. “Involuntary” is also used to describe instances when an individual is committed to outpatient treatment by a court. The fact that a person is being treated involuntarily raises numerous challenges; it raises concerns about protecting individual liberty, respect for patient autonomy, and the specter of past abuses of patients in psychiatric institutions.

Although it has become both a clinical colloquialism and legal touchstone, the concept of involuntary treatment is used imprecisely to describe all instances in which a patient has refused the treatment he or she subsequently receives. In some cases, a patient outwardly refuses treatment but may have previously expressed a desire to be treated in crisis or, according to a reasonable evaluator, he or she would have agreed to accept stabilizing treatment, such as antipsychotic medication. A similar scenario occurs in the treatment of individuals who experience a first episode of psychosis and who outwardly refuse treatment. With no prior experience of what it is like to have psychosis, these patients are unable to develop informed preferences about treatment in advance of their first crisis. In these cases, some believe it is reasonable to provide treatment despite the opposition of the patient, although this could be debated.

The article is here.

California Regulator Slams Health Insurers Over Faulty Doctor Lists

Chad Terhune
Kaiser Health News
Originally published February 13, 2017

California’s biggest health insurers reported inaccurate information to the state on which doctors are in their networks, offering conflicting lists that differed by several thousand physicians, according to a new state report.

Shelley Rouillard, director of the California Department of Managed Health Care, said 36 of 40 health insurers she reviewed — including industry giants like Aetna and UnitedHealthcare — could face fines for failing to submit accurate data or comply with state rules.

Rouillard said she told health plan executives in a meeting last week that such widespread errors made it impossible for regulators to tell whether patients have timely access to care in accordance with state law.

“I told the CEOs it looks to me like nobody cared. We will be holding their feet to the fire on this,” Rouillard said in an interview with California Healthline. “I am frustrated with the health plans because the data we got was unacceptable. It was a mess.”

The article is here.

Misguided mental health system needs an overhaul

Jim Gottstein
Alaska Dispatch News
Originally posted January 12, 2016

The glaring failures surrounding Esteban Santiago, resulting in the tragic killing of five people and wounding of eight others in Fort Lauderdale, Florida, prompts me to make some points about our misguided mental health system.

First, psychiatrists have no ability to predict who is going to be violent. In a Jan. 3, 2013, Washington Post article, "Predicting violence is a work in progress," after reviewing the research, writer David Brown, reported:

• "There is no instrument that is specifically useful or validated for identifying potential school shooters or mass murderers."

• "The best-known attempt to measure violence in mental patients found that mental illness by itself didn't predict an above-average risk of being violent."

• "(S)tudies have shown psychiatrists' accuracy in identifying patients who would become violent was slightly better than chance."

• "(T)he presence of a mental disorder (is) only a small contributor to risk, outweighed by other factors such as age, previous violent acts, alcohol use, impulsivity, gang membership and lack of family support."

The article is here.

Why doctors are leery about seeking mental health care for themselves

By Nathaniel P. Morris
The Washington Post
Originally published January 7, 2016

A survey of 2,000 U.S. physicians released in September found that roughly half believed they had met criteria for a mental health disorder in the past but had not sought treatment. The doctors listed a number of reasons they had shunned care, including worries that they’d be stigmatized and an inability to find the time.

But they also voiced a troubling reason for avoiding treatment: medical licensing applications.

After graduating from medical school, doctors must complete residency training and apply for state medical licenses to practice medicine. According to a study that appeared in 2008, about 90 percent of state medical boards have licensing forms that include questions about an applicant’s mental health.

Such questions are intended to protect the public, based on the idea that impaired or distressed physicians could endanger patients. A physician having hallucinations, for example, might not be able to focus or practice safely.

The article is here.

Gifts and influence: Conflict of interest policies and prescribing of psychotropic medications in the United States

Marissa King and Peter S. Bearman
Social Science & Medicine
Volume 172, January 2017, Pages 153–162

Abstract

The pharmaceutical industry spends roughly 15 billion dollars annually on detailing – providing gifts, information, samples, trips, honoraria and other inducements – to physicians in order to encourage them to prescribe their drugs. In response, several states in the United States adopted policies that restrict detailing. Some states banned gifts from pharmaceutical companies to doctors, other states simply required physicians to disclose the gifts they receive, while most states allowed unrestricted detailing. We exploit this geographic variation to examine the relationship between gift regulation and the diffusion of four newly marketed medications. Using a dataset that captures 189 million psychotropic prescriptions written between 2005 and 2009, we find that uptake of new costly medications was significantly lower in states with marketing regulation than in areas that allowed unrestricted pharmaceutical marketing. In states with gift bans, we observed reductions in market shares ranging from 39% to 83%. Policies banning or restricting gifts were associated with the largest reductions in uptake. Disclosure policies were associated with a significantly smaller reduction in prescribing than gift bans and gift restrictions. In states that ban gift-giving, peer influence substituted for pharmaceutical detailing when a relatively beneficial drug came to market and provided a less biased channel for physicians to learn about new medications. Our work suggests that policies banning or limiting gifts from pharmaceutical representatives to doctors are likely to be more effective than disclosure policies alone.

The article is here.

There may be no worse place for mentally ill people to receive treatment than prison

By The Spotlight Team
The Boston Globe
Originally posted November 25, 2016

Here is an excerpt:

Last year, more than 15,000 prisoners walked out of Massachusetts jails and prisons. More than one-third suffer from mental illness; more than half have a history of addiction. Thousands are coping with both kinds of disorders, their risk of problems amplified as they reenter society.

Within three years of being released, 37 percent of inmates who leave state prisons with mental illnesses are locked up again, compared with 30 percent of those who do not have mental health problems, according to a Department of Correction analysis of 2012 releases. Inmates battling addiction fare worse: About half are convicted of a new crime within three years, according to one state study. And inmates with a “dual diagnosis” of addiction and mental illness, like Nick Lynch, do the worst of all, national studies show.

Despite the vast need — and the potential payoff in reduced recidivism — mental health and substance abuse treatment for many Massachusetts inmates is chronically undermined by clinician shortages, shrinking access to medication, and the widespread use of segregation as discipline. The prison environment itself is a major obstacle to treatment: In a culture ruled by aggression and fear, the trust and openness required for therapy are exponentially harder to achieve.

And when their incarcerations end, many mentally ill and drug-addicted prisoners are sent back into the world without basic tools they need to succeed, such as ready access to medication, addiction counseling, or adequate support and oversight. Such omissions can be critical: The Harvard-led Boston Reentry Study found in 2014 that inmates with a mix of mental illness and addiction are significantly less likely than others to find stable housing, work income, and family support in the critical initial period after leaving prison, leaving them insecure, isolated, and at risk of falling into “diminished mental health, drug use and relapse.”

The article is here.

Episode 25: The Assessment, Management, and Treatment of Suicidal Patients

Suicide is the 10th leading cause of death in the United States and the most frequent crisis encountered by mental health professionals. This video/podcast reviews basic information about the assessment, management, and treatment of patients at risk to die from suicide. It fulfills Act 74 requirements for Pennsylvania licensed psychologists, social workers, marriage and family therapists, and professional counselors.

Program Learning Objectives:

At the end of this program the participants will learn basic information that will help them to

1. Assess patients who are at risk to die from a suicide attempt;
2. Manage the risks of suicide; and
3. Treat patients who are at risk to die from a suicide attempt.

Podcast

Video

Resources

Bongar, B., & Sullivan, G. (2013). The suicidal patient: Clinical and legal standards of care. (3rd ed.). Washington, DC: American Psychological Association.

Bryan, C. J. (2015). Cognitive behavior strategies for preventing suicidal attempts. NY: Routledge.

Jamison, K. R. (2000). Night Falls Fast: Understanding suicide. New York: Random House.

Jobes, D. (2016). Managing suicide risk (2nd Ed.). NY: Guilford.

Joiner, T. (2005). The myths of suicide. Cambridge, MA: Harvard University Press.

McKeon, R. (2009). Suicidal behavior. Cambridge, MA: Hogrefe & Huber.

Disclaimer

As an educational program, this podcast/video does not purport to provide clinical or legal advice on any particular patient. Listeners or viewers with concerns about the assessment, management, or treatment of any patient are urged to seek clinical or legal advice. Also, individual psychotherapists need to use their clinical judgment with their patients and incorporate procedures or techniques not covered in this podcast/video, or modify or omit certain recommendations herein because of the unique needs of their patients.

This one-hour video/podcast provides a basic introduction to the assessment, management, and treatment of patients at risk to die from a suicide attempt. This podcast/video may be a useful refresher course for experienced clinicians. However, listeners/viewers should not assume that the completion of this course will, in and of itself, make them qualified to assess or treat individuals who are at risk to die from suicide. For those who do not have formal training in suicide, this podcast/video should be seen as providing an introduction or exposure to the professional literature on this topic.

Proficiency in dealing with suicidal patients, like proficiency in other areas of professional practice, is best achieved through an organized sequence of study including mastery of a basic foundation of knowledge and attitudes, and supervision. It is impossible to give a fixed number of hours of continuing education and supervision that professionals need to have before they can be considered proficient in assessing, managing, and treating suicidal patients. Much depends on their existing knowledge base and overall level of clinical skill. It would be indicated to look at competency standards from noted authorities, such as those developed by the American Association of Suicidology ( http://www.sprc.org/training-events/amsr), by David Rudd and his associates (Rudd et al., 2008), or Cramer et al. (2014).

After you review the material, click here to link to CE credit.

Click here for slides related to the podcast.

How Artificial Intelligence Could Help Diagnose Mental Disorders

Joseph Frankel
The Atlantic
Originally posted August 23, 2016

Here is an excerpt:

In addition to the schizophrenia screener, an idea that earned Schwoebel an award from the American Psychiatric Association, NeuroLex is hoping to develop a tool for psychiatric patients who are already being treated in hospitals. Rather than trying to help diagnose a mental disorder from a single sample, the AI would examine a patient’s speech over time to track their progress.

For Schwoebel, this work is personal: he thinks this approach may help solve problems his older brother faced in seeking treatment for schizophrenia. Before his first psychotic break, Schwoebel’s brother would send short, one-word responses, or make cryptic to references to going “there” or “here”—worrisome abnormalities that “all made sense” after his brother’s first psychotic episode, he said.

The article is here.

An NYU Study Gone Wrong, and a Top Researcher Dismissed

By Benedict Carey
The New York Times
Originally posted June 27, 2016

New York University’s medical school has quietly shut down eight studies at its prominent psychiatric research center and parted ways with a top researcher after discovering a series of violations in a study of an experimental, mind-altering drug.

A subsequent federal investigation found lax oversight of study participants, most of whom had serious mental issues. The Food and Drug Administration investigators also found that records had been falsified and researchers had failed to keep accurate case histories.

In one of the shuttered studies, people with a diagnosis of post-traumatic stress caused by childhood abuse took a relatively untested drug intended to mimic the effects of marijuana, to see if it relieved symptoms.

The article is here.

Cook County Sheriff Dart: Jailing poor, mentally ill is unjust

Madhu Krishnamurthy
Daily Herald
Originally posted April 6, 2016

The numbers of mentally ill people housed in the nation's prisons and jails are staggering, Cook County Sheriff Tom Dart says, and many of them shouldn't be there.

Dart, speaking Wednesday at Elgin Community College, has led a campaign to reduce what he calls the unjust incarceration of the poor and mentally ill. He's been recognized by health advocacy organizations for trying to change the criminal justice system, which perpetuates a revolving door at jails. His presentation was part of the college's Humanities Center Speakers series.

The article is here.

Outsourcing the Mentally Ill to Police

By Rich Lowry
The National Review
Originally posted January 1, 2016

Here is an excerpt:

In its analysis of 2015 police shootings, the Post found dozens of cases in which the police were called as a means of getting treatment. Shirley Marshall Harrison called the Dallas police when her schizophrenic, bipolar son was out of control. He was shot down while allegedly charging police with a screwdriver. “I didn’t call for them to take him to the morgue,” she said of the cops. “I called for medical help.”

It’s a poignant lament, but why do the families of the severely mentally ill need to rely on the police for medical assistance? When someone has a heart attack or gets cancer, we don’t call the police.

The opinion piece is here.

Decreasing mental health services increases mental health emergencies

Science Daily
Originally published November 20, 2015

Countywide reductions in psychiatric services -- both inpatient and outpatient -- led to more than triple the number of emergency psychiatric consults and 55 percent increases in lengths of stay for psychiatric patients in the emergency department. The before and after study of the impact of decreasing county mental health services was published online in Annals of Emergency Medicine ('Impact of Decreasing County Mental Health Services on the Emergency Medicine').

"As is often the case, the emergency department catches everyone who falls through the cracks in the health care system," said lead study author Arica Nesper, MD, MAS of the University of California Davis School of Medicine in Sacramento. "People with mental illness did not stop needing care simply because the resources dried up. Potentially serious complaints increased after reductions in mental health services, likely representing not only worse care of patients' psychiatric issues but also the medical issues of patients with psychiatric problems."

The entire article is here.

When Students Become Patients, Privacy Suffers

By Charles Ornstein
ProPublica
Originally published October 23, 2015

Here is an excerpt:

Yale Health’s website informs parents that they cannot access their child’s health information without a signed written consent form. Andrea said she does not recall signing that document. When she recently asked to see any such form, she said, she was told by the counseling center’s chief that there was none. “Most of what happened while I was in the hospital happened without my knowing it,” she said. “I got an update every day or two about where my life was going.”

Andrea’s case is a vivid demonstration of how weaknesses in state and federal laws — and the often-conflicting motives of students, parents, and college officials — have left patient privacy vulnerable when students receive medical treatment on campus.

Universities walk a fine line when providing that treatment or mental-health services to students. If campus officials don’t know what’s going on or disclose too little, they risk being blamed if a student harms himself, herself, or others. If they pry too deeply, they may be accused of invading privacy, thereby discouraging students from seeking treatment.

The entire article is here.

How Patient Suicide Affects Psychiatrists

By Sulome Anderson
The Atlantic
Originally posted January 20, 2015

It’s hard to listen to a psychiatrist who sounds so broken. I expect a mental-health provider to seem healthy, detached. But even over the phone, the weariness in Dr. Brown’s voice is palpable.

“This is what we do when people die,” he says. “Even if they die an expected death, it seems to be human nature to go back over [it]. What should I have said that I didn't, or shouldn’t have said that I did? Could I have done more or did I do too much? This seems to be a part of the grieving process. I think it's especially intense in a situation where you have direct responsibility for helping the person get better.”

Brown lost a patient to suicide last year. She was a long-term client of his, the mother of a large, loving family. Right after a session with him, she went home and killed herself. Two months later, Brown’s son did the same thing.

The entire article is here.

The Impact of Mental Illness Stigma on Seeking and Participating in Mental Health Care

Patrick W. Corrigan, Benjamin G. Druss, and Deborah A. Perlick
Psychological Science in the Public Interest 2014, Vol. 15(2) 37–70.

Summary 

Treatments have been developed and tested to successfully reduce the symptoms and disabilities of many mental illnesses. Unfortunately, people distressed by these illnesses often do not seek out services or choose to fully engage in them. One factor that impedes care seeking and undermines the service system is mental illness stigma. In this article, we review the complex elements of stigma in order to understand its impact on participating in care. We then summarize public policy considerations in seeking to tackle stigma in order to improve treatment engagement. Stigma is a complex construct that includes public, self, and structural components. It directly affects people with mental illness, as well as their support system, provider network, and community resources. The effects of stigma are moderated by knowledge of mental illness and cultural relevance. Understanding stigma is central to reducing its negative impact on care seeking and treatment engagement. Separate strategies have evolved for counteracting the effects of public, self, and structural stigma. Programs for mental health providers may be especially fruitful for promoting care engagement. Mental health literacy, cultural competence, and family engagement campaigns also mitigate stigma’s adverse impact on care seeking. Policy change is essential to overcome the structural stigma that undermines government agendas meant to promote mental health care. Implications for expanding the research program on the connection between stigma and care seeking are discussed.

The entire article is here.