Wednesday, February 15, 2012

My Thoughts on Marriage

I've worked with patients who are getting married, patients who are getting engaged, and patients who are getting separated or divorced. These different experiences have convinced me that some people underestimate or misunderstand marriage.

Occasionally I've had patients who have been in long term relationships without getting married tell me that marriage is "just a piece of paper." If that were true, why would gay people be fighting for the right to get married? Legally, marriage has certain benefits. But more importantly, it's a public declaration of a relationship.

A few years ago, someone wrote a popular book, "He's Just Not That Into You," which included a chapter called "If He's Not Marrying You, He's Just Not That Into You." It's true. If a man really wants to commit to a woman, he wants to marry her. If he doesn't want marriage, it's because he wants to keep his options open.

Marriage includes legal responsibilities toward a spouse. Sometimes, people who really, really want to be married marry someone who isn't financially responsible, truthful or ethical. Later, they find out that they are responsible for their spouse's debts. Don't marry someone who mismanages money or who is dishonest. You will regret such a decision.

I've found that people also underestimate the trauma of divorce. Depending on many factors, divorces can take years and cost thousands of dollars or tens of thousands of dollars in legal fees.

People tend to evaluate prospective marital partners based on shared interests and goals and on sexual attraction. Although these things may be important, it's just as important to marry someone who is a good person and who really wants to be married. Don't marry someone who's ambivalent about marriage and don't marry someone who can't be trusted. Better to stay single than have a bad marriage with a bad divorce.

Thursday, January 12, 2012

Government Concerned About Possible Overuse of Anti-Psychotic Medications in Children and the Elderly

One of the psychiatrists I work with forwarded me the following release from the American Psychiatric Association, which I've edited down for brevity:

APA cites a need to use practice guidelines when prescribing antipsychotics in nursing homes and foster-care facilities.

"New research on alleged overuse of psychotropic medications in both nursing-home and foster-care settings signals a need for better training of nonpsychiatric physicians and increased funding to bolster the mental health workforce, stated APA in recently submitted congressional testimony.
On November 30, 2011, the Senate Special Committee on Aging held a hearing exploring an audit issued earlier in the year by the Department of Health and Human Services’ (HHS) Office of Inspector General (OIG). The report found that 14 percent of nursing-home residents were prescribed an atypical antipsychotic during the first six months of 2007.
One day later, the Senate Homeland Security and Government Affairs’ Subcommittee on Federal Financial Management, Government Information, Federal Services, and International Security heard testimony from the Government Accountability Office (GAO) that foster children are prescribed psychotropic drugs at a significantly higher rate than children not in foster care.
According to the OIG, 20 percent of the 8.5 million Medicare claims made for atypical antipsychotics during the review period were submitted on behalf of elderly nursing-home residents. Of these claims, 83 percent were associated with off-label conditions and 88 percent were associated with dementia.
The report also found that 51 percent of the nursing-home claims failed to comply with Medicare reimbursement criteria, at a cost of $116 million. In these instances, the drugs were either not used for medically accepted indications or not documented as having been administered to the residents.
Additionally, 22 percent of the anti-psychotics for which reimbursement claims were filed were not administered in accordance with standards issued by the Centers for Medicare and Medicaid Services (CMS) regarding drug regimens in nursing homes.
Reason for Prescription Not Evaluated
“The report didn’t investigate why patients with dementia are prescribed antipsychotic drugs so often,” noted OIG Inspector General Daniel Levinson in a May 31, 2011, editorial for CNN. “But a series of lawsuits and settlements that my office helped bring about suggests that many pharmaceutical companies have improperly promoted these drugs to doctors and nursing homes for many years.”
In its statement to the Senate hearing on this issue, APA referred to its 2007 practice guideline on the treatment of patients with Alzheimer’s disease and other forms of dementia, stressing that APA “strongly supports the use of nonpharmacological interventions and regular psychosocial treatments for patients with dementia.”
“Our guidelines recommend that off-label usage of antipsychotics in low doses be considered as a treatment option when a moderately, severely, or profoundly impaired patient’s psychotic symptoms cause significant distress or threaten the lives and safety of others,” said APA Medical Director James Scully Jr., M.D. “We urge physicians to weigh very carefully the potential benefits of antipsychotics . . . with their potential drawbacks.”
“APA strongly opposes any practice or pattern of prescribing antipsychotics for reasons of convenience or without clear medical indicators,” Scully added.

Are Foster Children Overmedicated?

On another issue related to concerns about use of antipsychotics, the GAO in recent congressional testimony compared the number of foster children being prescribed psychotropic medications in 2008 with the rate of prescriptions for nonfoster children and examined state oversight of psychotropic prescriptions for foster children through October 2011.
While APA acknowledged in its statement in conjunction with the Senate hearing that children in foster-care systems experience high rates of mental illness, it voiced support for the GAO’s recommendation that HHS issue formal guidance to state Medicaid and child-welfare agencies on best practices for monitoring the prescription of psychotropic medications for foster children.
“APA strongly believes psychotropic medications must be prescribed only when appropriately deemed necessary, and must form part of a larger customized treatment plan that includes both psychopharmacologic and psychosocial interventions,” Scully said in his testimony.