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.
Wednesday, February 15, 2012
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.
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.
Saturday, December 10, 2011
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.
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.
Sunday, October 16, 2011
"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.
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.
Monday, September 26, 2011
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
http://www.psychologytoday.com/blog/save-your-sex-life/201109/reconnecting-couples-using-physical-intimacy
Wednesday, August 24, 2011
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.
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.
Thursday, August 11, 2011
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.
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.
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