GPs Reminded to Regularly Assess Depressed Patients for Risk of Suicide

Originally Published on May 4, 2012

The Medical Defence Union

GPs are being advised to ensure patients with depression are regularly assessed for a risk of suicide. The Medical Defence Union (MDU) issued the advice after being notified of a small number of complaints in which GPs were criticised for failing to appreciate that the patient was a suicide risk.

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The MDU's advice for GPs to help them avoid such problems includes:

• Be aware of the current guidance on the treatment of depression, including the role of non-drug interventions.
• Ensure patients understand what is being prescribed and have been warned about the risks involved, any side-effects and alternatives to treatment.
• Have a system in place to review patients on long-term medication.
• All patients who present with depression need to be assessed regularly for risk of suicide.
• Be prepared to refer patients for specialist treatment where necessary and have a system to track referrals.
• Take care with prescriptions for drugs with similar names and with dosages.

The entire story is here.

NY Fines 15 Insurers over Mental Health Notices

Associated Press
The Wall Street Journal
Originally published May 9, 2012

ALBANY, N.Y. — New York regulators have fined 15 insurers $2.7 million for failing to notify small businesses they were eligible to buy special coverage for mental illnesses and children with serious emotional disturbances.

Superintendent of Financial Services Benjamin Lawsky says they are the first fines under Timothy's Law, named for a teen who committed suicide after his parents were unable to obtain needed mental health treatment. The law took effect in 2007.

The rest of the story is here.

More information on Timothy's Law is here.

Psychoactive Medication Use Among Children In Foster Care

The Children's Hospital of Philadelphia
"Hope Lives Here"
Originally published April 30, 2012

A few months after the federal Government Accountability Office (GAO) issued a report on the use of psychoactive drugs by children in foster care in five states, a national study from PolicyLab at The Children's Hospital of Philadelphia describes prescription patterns over time in 48 states. The updated findings show the percentage of children in foster care taking antipsychotics - a class of psychoactive drugs associated with serious side effects for children - continued to climb in the last decade. At the same time, a slight decline was seen in the use of other psychoactive medications, including the percentage of children receiving 3 or more classes of these medications at once (polypharmacy).

Psychoactive drugs prescribed at higher rates for foster children

As public scrutiny has increased about the use of psychoactive medication by children over the past decade, children in foster care continue to be prescribed these drugs at exceptionally high rates compared with the general population of U.S. children. According to the PolicyLab study, 1 in 10 school-aged children (aged 6-11) and 1 in 6 adolescents (aged 12-18) in foster care were taking antipsychotics by 2007.

The entire story is here.

Contact: Dana Mortensen, Children's Hospital of Philadelphia, 267-426-6092

Vignette 13: Troubles in the ICU

You are a psychologist in a busy acute care hospital where you receive frequent consultation requests by the trauma service.  A physician requests a psychological evaluation of a 46-year-old man who attempted suicide via over dose of prescription medications along with alcohol. You arrive in the intensive care unit where the patient’s respiratory status is rapidly deteriorating. He is marginally coherent and unable to give any consistent responses.  However, upon his arrival in the emergency department, the medical record quotes the patient as saying, “This wasn’t supposed to have happened.”

The ICU nurse asks you to offer an opinion regarding the patient’s capacity to accept or refuse intubation.

While you are there, a family member arrives with a copy of a notarized advance directive, created within the last year, which specifically outlines the patient’s wishes not to be placed on a ventilator or any artificial life support. The ICU staff asks for your input.

What are the ethical issues involved?

What would you do in this situation?

Would your answer differ if the advanced directive was created 7 years ago or greater?

Would your answer differ if there were no advanced directives?

Record Keeping in the Cloud: Ethical Considerations

*Professional Psychology: Research & Practice" has scheduled an article for publication in a future issue of the journal: "Record Keeping in the Cloud: Ethical Considerations."

The authors are Robert L. Devereaux and Michael C. Gottlieb.

Here's an excerpt: "In this article, we briefly review technological advances in electronic storage, define "the cloud" and explain how it functions, discuss risks and benefits of its use, and provide questions for practitioners when considering the appropriateness of maintaining patient records in this manner."

Here's another excerpt: "Consider the following example. A practitioner, using an online patient management system, decides to change service providers for any number of reasons (e.g., cost, poor service). The stored patient data may be contained within a proprietary system that cannot be easily migrated to a new system/provider. As mentioned previously, online service providers each have a unique system and moving from one to another might require unknown amounts of time, resources, and temporary loss of access to patient records during the move. In addition to the possible frustration of a transition process, it would be important for the practitioner to understand how data are deleted from the old system. For example, Facebook, a cloud-based social profile software system, maintains user accounts even after they are inactivated at the user's request. Permanently deleting the account is much more involved, and there is no way of knowing if Facebook maintains historical records of old accounts, although this may be discussed in their Terms and Conditions of Use Agreement. This could also be the case for other online storage or electronic medical record companies, and practitioners are well advised to investigate this matter before agreeing to store records on the cloud. Also, a practitioner would need to decide how much information to disclose to clients as part of a continued informed consent process if/when he or she decides to move records from one company to another. Such disclosure would need to be consistent with the level of detail about record keeping provided to the client at the onset of treatment."

Here's how the article concludes: "With the broad spectrum of electronic storage and management options available to practitioners, the abdication of control to a third-party, cloud-based company may represent unnecessary additional risk at this relatively early stage. In part, aggregation of documents from users worldwide may create a much more appealng target for malicious hackers than a single office with only a few patient documents. Also, the question of liability has not yet been clearly defined. We are responsible for protecting patient information, but computing companies carry no such obligation beyond their own internal policies and contractual obligations. We recommend that practitioners who move their EHR to the cloud do so with caution and careful consideration of the accompanying risks and benefits."

The author note provides the following contact information for reprint requests, questions, or comments: Robert

L. Devereaux, Division of Psychology, Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX 75390-9044;  E-mail: robert.devereaux@utsouthwestern.edu

Thanks to Ken Pope for this information.

Link to APA's Record Keeping Guidelines

Stressed physicians reluctant to seek support

They cite lack of time and fear of hurting their careers as reasons to avoid employee-assistance programs.

By KEVIN B. O'REILLY, amednews staff

Nearly 80% of physicians at an academic medical center said they experienced a personal crisis within the past year, yet most said they would not seek support from physician-health services or employee-assistance programs.

The 108 surgeons, anesthesiologists and emergency physicians surveyed said they experienced a wide range of stressful events, such as serious illnesses or deaths in their families and severe adverse events in their patients. But most they said they were unlikely to turn to institutional sources of support, with 40% saying they would be willing to consult physician-health services and 29% open to using employee-assistance programs. About a third of the doctors had never even heard of these services, said an Archives of Surgery study published in March.

The reason offered most frequently for not getting help was lack of time, with 90% of the physicians surveyed at Brigham and Women’s Hospital in Boston citing it. About 70% feared a lack of confidentiality, negative impact on their careers or the stigma of mental illness. Nearly half feared legal consequences or thought “using services means I am weak.”

The entire story is here.

The original abstract is here.

Conflicts Arise As Health Insurers Diversify

By Jay Hancock
Kaiser Health News
Originally published April 29, 2012

Like hospitals and doctorseverywhere, Banner Health fights a daily battle to get paid by insurance companies and government agencies for the care it delivers.

So the hospital system hired a company called Executive Health Resources to fight back against the likes of Medicare and UnitedHealthcare when they deny claims or pay bills for less than what Banner thinks it is owed.

But Banner executives began to worry about EHR's independence when the firm was acquired in 2010 by UnitedHealth Group, UnitedHealthcare's parent.

"It does seem as though there is reason for concern because they can use our own information against us," said Dennis Dahlen, CFO of the Phoenix-based Banner.

Critics call United's ownership of EHR a troubling conflict of interest that could give it confidential information about rivals as well as patients and limit EHR's power to demand payment from its much larger corporate sister. "How is that ownership going to affect the mission of a company whose business is to extract more money from payers?" said Scot Silverstein, a physician and specialist in medical software and patient records at Drexel University. "Imagine going to a plaintiff's lawyer to take your malpractice case and not knowing that plaintiff's lawyer actually works for the hospital that you're suing."

The entire story is here.

U.S. Charges 107 With Defrauding Medicare

By Louise Radnofsky
Wall Street Journal
Originally published on May 2, 2012

Federal officials said Wednesday they had charged 107 people across the country in recent days for allegedly running a string of unrelated Medicare fraud schemes involving a total of $452 million in false claims.

Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius said that charges were being brought against defendants in seven cities, including doctors and nurses, for seeking to defraud the federal health program for the elderly and disabled. At least 83 of the defendants were arrested Wednesday morning, officials said.

Among those arrested were seven people in Baton Rouge, La., who were accused of recruiting elderly, mentally ill and drug-addicted patients from nursing homes and homeless shelters.

The entire story is here.

Bounded Ethicality: The Perils of Loss Framing

By Mary C. Kern and Dolly Chugh

Psychological Science

(2009) Volume 20, Number 3, pp 378-384

Abstract

Ethical decision making is vulnerable to the forces of automaticity. People behave differently in the face of a potential loss versus a potential gain, even when the two situations are transparently identical. Across three experiments, decision makers engaged in more unethical behavior if a decision was presented in a loss frame than if the decision was presented in a gain frame. In Experiment 1, participants in the loss-frame condition were more likely to favor gathering ‘‘insider information’’ than were participants in the gain-frame condition. In Experiment 2, negotiators in the loss-frame condition lied more than negotiators in the gain-frame condition. In Experiment 3, the tendency to be less ethical in the loss-frame condition occurred under time pressure and was eliminated through the removal of time pressure.

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Framing

In the studies reported here, we explored the effect of automaticity on the cognitions and behaviors of decision makers in the moment of ethical choice. What are the roles of the decision maker’s cognitive framing of the situation and the decision maker’s available cognitive resources?  We turned to framing effects (Tversky & Kahneman, 1981) as the foundation of our inquiry.  The transformative effects of framing are well established (for reviews, see Camerer, 2000; Kuhberger, 1998). A framing effect occurs when transparently and objectively identical situations generate dramatically different decisions depending on whether the situations are presented, or perceived, as potential losses or gains (Tversky & Kahneman, 1981). Framing effects are integral to prospect theory (Kahneman & Tversky, 1979; Tversky & Kahneman, 1981), a model of choice that describes an ‘‘S-shaped value function’’ to illustrate the differences in how gains and losses, relative to a reference point, are valued. A critical feature of this curve is that it has a steeper slope in the loss domain than in the gain domain. As a result, people are loss averse; that is, they are willing to go to greater lengths to avoid a loss than to obtain a gain of a similar size (Kahneman, Knetsch, & Thaler, 1990; Tversky & Kahneman, 1991).

We considered the implications of framing effects for ethics.  When making decisions, individuals often choose from an array of possible responses, with some choices being more, or less, ethical than others. Given the previous work on framing effects, we reasoned that individuals who perceive a potential outcome as a loss will go to greater lengths, and engage in more unethical behavior, to avert that loss than will individuals who perceive a similarly sized gain. This logic formed the initial basis for the present research.

The entire article is here.