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.

Seeing is Believing

The proof is in the pudding. Don't count your chickens before they're hatched. A bird in the hand beats two in the bush.

There are so many old adages that say virtually the same thing. Yet, there is no shortage of persons who come to my office--usually women--who are angry and puzzled because a man with whom they've been involved didn't do as he said.

The oldest rule of psychology is that past behavior is the best predictor of future behavior. If you want to know what someone's future behavior is likely to be, don't listen to what the person promises. Look at his or her past behavior. Yes, people can change. But they usually don't. Trust me; if everyone who could change their behavior came to psychotherapy in order to change that behavior, I would have a lengthy waiting list and so would every other therapist, and we would all be rich. I fly economy class. Most people with negative behaviors and personality problems never go to therapy and aren't interested. A man who is a chronic cheat or a habitual liar is unlikely to become a different person. In most cases, his cheating and lying works for him and he doesn't care how it affects others.

You (probably) deserve better. This advice is free.

"Medicare for All" Would Not Be A Panacea

"Medicare for All" is a slogan I've been hearing a lot lately. Unfortunately, those of us who have been Medicare providers know that this would be no panacea for our nation's healthcare woes.

I've stopped accepting Medicare patients. I got tired of re-submitting the same claim form 3 times because an i wasn't dotted or a t wasn't crossed. I also found it impossible to find out in advance how much I would be paid, which is not the same rate for every patient.
I had a patient who had Medicare and Medicaid, and when I tried to bill Medicaid for the co-pay--the usual procedure--I was told I could not, for unclear reasons, but also that I could not bill the patient. I ended up being paid $50 per session for this patient, which is below my lowest fee.
When I signed up for electronic funds transfer, it took Medicare more than 6 months to process my one-page application form.
When I didn't get paid for a patient for unclear reasons, I had to get my Member of Congress to intervene before I was finally paid.

I believe the general public is unaware of how difficult and unprofitable it is for healthcare providers to deal with Medicare. It's naive to think "Medicare for All" would mean guaranteed healthcare, because an increasing number of providers no longer accept Medicare. Health insurance is useless if healthcare providers won't accept it as payment.

Tips for Rekindling Desire

I thought this marriage counselor's blog post had some good tips about sex:

http://www.psychologytoday.com/blog/save-your-sex-life/201109/reconnecting-couples-using-physical-intimacy

Why I Don't Make Appointments Via Third Parties

About once a month, someone contacts me to make an appointment for a friend or relative. I no longer respond to these calls, because I don't have time. The fact is I don't take third party referrals, because I know the person won't show up if someone else makes the appointment.

I've pondered whether the person making the call really believes that their relative, friend or significant other will attend an appointment made by someone else. It's occurred to me these individuals making the calls may just want to be able to tell themselves that they tried to help. A better way to help someone is to tell the person what your limits are. If you find someone's behavior to be intolerable, the best thing for you to do is to stop tolerating it. Doing work for them that they could do themselves, such as making a psychotherapy appointment, does not help. If someone won't make a phone call to set up an appointment for treatment, that person definitely is not going to actually go to such an appointment. Going to therapy is a lot harder than making an appointment for therapy.

Let Them Smoke

It's an old joke among mental health workers that people with schizophrenia live for three things: Coffee, food and cigarettes. Schizophrenics still have access to food and coffee, but today we live in a country in which smoking is forbidden in most places and the cost of a pack of cigarettes is prohibitive for the poor--and most people with severe mental illness are poor.

These changes were made for the benefit of "society", but the people whom they benefit are primarily middle-class people who can quit smoking if they choose to do so. The laws punish those who have the hardest time quitting smoking (and may have no incentive to do so) and can least afford the financial cost of cigarettes.

People with the worst cases of chronic schizophrenia live in state psychiatric hospitals, where smoking is forbidden. Even if they had the money, they could not choose to smoke.

Years ago, a schizophrenic patient commented to me that he didn't understand how I could drink coffee without smoking cigarettes--"because the coffee brings you up, and then the cigarettes even you out." Some may think that the psychiatric medications our pharmaceutical companies have created are substitutes for cigarettes and coffee, but they aren't. They don't provide pleasure nor do they have a social aspect. And many of them cause weight gain and diabetes. Diabetes is a fatal illness--a fact many people forget. Smoking kills, but so does obesity.

Well-meaning policymakers--as well as grandstanding politicians--often don't think about the consequences of their actions on society's vulnerable members.

Nanny Diaries

I've had several patients who were nannies, and other patients who hired nannies. I realize some people need nannies to watch their children, but I believe hiring a nanny should be a last resort.

People hire nannies based usually on the nanny's references. These references are from adults who hired the nannies. The only people who can actually report on the nannies' behavior, however, are the children. Parents often have no idea what is really going on between the nanny and the children. A publicized example of this can be seen in the film "The King's Speech," in which Colin Firth's character reveals that he was victimized by his nanny. If the future King of England doesn't get a good nanny, how can anyone know for sure that the nanny they hire is any good? They can't.

Abusive nannies are almost certainly in the minority. A more common, almost inescapable problem occurs when the nanny is good. The children bond with the nanny, seeing her as another parent. Many biological parents are probably in denial about the parent-child bond that can develop between nannies and children. When the children get older and no longer need a nanny, the nanny is typically fired. She may or may not continue some contact with the children. Children who lose a parent before age 11 are at higher risk for depression as adults. Losing a nanny can be just like losing a parent. Could this be the reason why so many children of the wealthy seem to end up on drugs or as suicides?

Daycare, which offers less individualized attention but more peer interaction, is a healthier choice than a nanny.