Rx Medicaid Managed Care Draws Mental Health Concerns

Big changes in Rhode Island's Medicaid formulary are raising big concerns among mental health advocates. The General Assembly authorized the state Department of Human Services to create a preferred drug list that would limit the drugs covered by Medicaid and switch patients to generics whenever possible. The DHS sought public feedback in a hearing last week. Advocates for the mentally ill pleaded to exclude mental-illness medications from the new regulations. A preferred drug list could have a "devastating" effect because it would "force physicians to choose medications that they otherwise would not prescribe," Chaz Gross, executive director of the National Alliance on Mental Illness-Rhode Island, said at the hearing. Though anti-psychotics are specifically excluded under the new law, the advocates also are seeking to exempt antidepressants, anti-anxiety medications, and anti-convulsants.

Mental Health Research: Into the Future

In the six decades that NIMH has led the nation's research effort in mental health, advancement has been dramatic. We understand now that the major mental disorders are brain disorders, with specific symptoms rooted in abnormal patterns of brain activity. We realize that the devastation of autism and schizophrenia are not the result of bad parenting or early psychic conflict. We recognize that mental disorders, unlike most chronic medical disorders, generally begin in childhood, with 50 percent of affected adults reporting onset of symptoms before age 14. We now have reliable diagnostic tools as well as effective medications and psychological therapies for depression and anxiety disorders; we have treatments that can predictably reduce the hallucinations and delusions of schizophrenia, as well as psychosocial interventions that enable people with schizophrenia to remain in their communities, to work and lead productive lives. The number of patients in state hospitals has decreased from 600,000 to less than 60,000.

While research funded by the National Institute of Mental Health (NIMH), part of the National Institutes of Health, has resulted in profound advancement in most of the major mental illnesses, in 2006 we recognize that not all treatments work for everyone. After six decades of progress, mental disorders remain unacceptably common, causing more disability in people under age 45 than any other class of non-communicable medical
illness.

How can we do better? Read more by linking to the National Institute of Mental Health website @ Into the Future

Evidence-Based Medicine: A Myth in the Making

Business Week had a wonderful cover article recently about the myth of evidence-based medicine, as Dr. David Eddy has spent a career in illustrating to other doctors and anybody else who will listen. As noted below, somewhere in the range of 20-25% of our medicine practices are evidence-based — that is, there is strong objective research evidence to support a particular treatment or intervention for a particular medical problem or disease. Most of what doctors do is based upon their own clinical judgment — judgment, which is often based upon conventional wisdom (”This is just how we’ve always treated this problem”), which is often just plain wrong.

He proved that doctors had little clue about the success rate of procedures such as surgery for enlarged prostates. He traced one common practice — preventing women from giving birth vaginally if they had previously had a cesarean — to the recommendation of one lone doctor. Indeed, when he began taking on medicine’s sacred cows, Eddy liked to cite a figure that only 15% of what doctors did was backed by hard evidence.

It could be said the practice of medicine across healthcare, including mental health could benefit from some attention and review of medical intervention models.

For more on this topic, go to Evidence-based Medicine

Suicidal Americans Missing Out on Care

Only half of suicidal people surveyed in a new study said they received significant mental health treatment during the previous year.

The odds of getting assistance were especially high among people who didn't think they had anything wrong with them despite having thoughts of killing themselves, the researchers said. But even those who realized they were in trouble sometimes couldn't get care.

"It's good if you perceive a need for help, but it doesn't solve all the problems," said study co-author Ruth Klap, an assistant research sociologist at the University of California at Los Angeles (UCLA).

The problem appears to be nationwide: A second study -- a survey of more than 3,500 people in five states -- found that less than 15 percent of those with symptoms of clinical depression were getting recommended care. In the UCLA study, Klap and her colleagues examined the results of a 2000-2001 survey of nearly 7,900 Americans. Among other things, the survey asked participants about suicidal thoughts and access to mental health care; the study was designed to include a higher than normal proportion of poor and psychologically stressed people. The study findings appear in the July-August issue of General Hospital Psychiatry.

In many cases, suicidal people are male -- known to be less likely to seek help than females -- and isolated from others. "One of the best protective factors is being able to form good and meaningful nurturing relationships," Berman said. "They become suicidal in part because they have trouble doing that." To make matters worse, doctors and mental health workers often aren't well-trained in how to assess suicidal people, he said. "That's just not being done very well," he noted.


For additional research findings on this topic, visit Suicide.

Are antidepressants working faster than initially thought?

Antidepressant benefit may be apparent sooner
Timothy F. Kirn
TORONTO - Most clinical recommendations advise that patients who start an antidepressant be given 4-6 weeks to see whether they respond and have improvement.
But an analysis of more than 5,000 patients treated in clinical trials with a variety of antidepressants suggests that most patients who respond well start to improve within 2 weeks, Dr. Armin Szegedi said at the annual meeting of the American Psychiatric Association.
"This is a very strong, clinically relevant, and, perhaps to many, a surprising finding," said Dr. Szegedi, executive director of clinical projects, psychiatry, at Organon International Inc., Rosalind, N.J., in an interview.
The analysis included patients who were treated with six different, selective serotonin reuptake inhibitors, including paroxetine (Paxil) and fluoxetine; two tricyclic antidepressants, amitriptyline and doxepin; and venlafaxine (Effexor), a selective norepinephrine reuptake inhibitor.
More...© 2006 Elsevier Inc. All rights reserved

Increase in Hospitalization for Young Females with Depression

The Center for Disease Control published data on July 6,2006 indicating a shape increase in hospitalization rates for female ages 5-19 from 1990-1992 to 2002 -2004 11.2 per 100,00o to 27.8 per 100, 000. The rate of hospitalization for depression increased approximately 81% for females aged 5--19 years. The rate for young females was nearly twice that for young males during 2002--2004.

What does this mean for clinicians and the population at large? We can speculate about the causes of this increase which may include more pressure on young women to be a certain way, changes in the family structure that create more adjustment for all of our children. As clinicians and community members, what are ways that we can improve prevention and early intervention with these young ladies? Schools are finding the need for mental health professionals in the school although sadly the resources to fund these professionals are diminishing. These are the first programs to go when schools are trying to find monies to continue with their core mission which is to provide the children with an education.

Nonmedical Pain Medication Abuse

2.4 Million Started Using Pain Relievers in Past Year

More persons initiated nonmedical use of narcotic pain relievers in the past year than initiated use of marijuana or cocaine. This is the finding of a new report from the Substance Abuse and Mental Health Services Administration that extracted data from the 2004 National Survey on Drug Use and Health.

The new report, “Nonmedical Users of Pain Relievers: Characteristics of Recent Initiates”, shows that 2.4 million persons ages 12 or older initiated nonmedical use of prescription pain relievers in the 12 months prior to the survey, 2.1 million initiated use of marijuana, and 1 million initiated use of cocaine.

“While overall illicit drug use continues to decline among our young people we are always paying close attention to the data to identify any potential areas of concern,” said SAMHSA Administrator Charles Curie. “Abuse of prescription pain medication is dangerous and can lead to the destructive path of addiction. The initiation rates show we must continue our efforts help the public confront and reduce all drug abuse.”

The new report shows that 48 percent of new initiates used Vicodin®, Lortab® or Lorcet®; 34.3 percent used Darvocet®, Darvon®, or Tylenol® with codeine; 20 percent used Percocet®, Percodan® or Tylox®; 18.4 percent used generic hydrocodone; 14.3 percent used generic codeine; 8.4 percent used Oxycontin®; and 4.3 percent used morphine. Over half of persons who initiated nonmedical use of pain medications (54.9 percent) in 2004 were female.

Further, the report found that only 26.2 percent of the new initiates to pain medications started using pain relievers as their first illicit drug of abuse. Marijuana was used by 66.2 percent prior to starting narcotic pain medications; hallucinogens were used by 24.9 percent; and inhalants were used by 21.3 percent.

The report is available on the web at http://www.oas.samhsa.gov/

Obesity Linked with Mood and Anxiety Disorders

Results of an NIMH-funded study show that nearly one out of four cases of obesity is associated with a mood or anxiety disorder, but the causal relationship and complex interplay between the two is still unclear. The study is based on data compiled from the National Comorbidity Survey Replication, a nationally representative, face-to-face household survey of 9,282 U.S. adults, conducted in 2001-2003. It was published in the July 3, 2006, issue of the Archives of General Psychiatry.

The results appear to support what other studies have found—that obesity, which is on the rise in the United States, is associated with increasing rates of major depression, bipolar disorder, panic disorder and other disorders. However, in contrast to other studies, this study found no significant differences in the rates between men and women. In addition, it found that obesity was associated with a 25 percent lower lifetime risk of having a substance abuse disorder. Obesity is defined as having a body mass index of 30 or more.

Link to the NIMH website for this complete article and other related mental health topics. Obesity & mental illness.

Distress: The Sixth Vital Sign?

In assessing a patient's condition, doctors traditionally check five vital signs -- pulse, breathing, temperature, blood pressure and pain. But one cancer physician wants to add another vital sign to the list -- distress.

A patient's mental well-being is an essential part of overall health and should be monitored -- even during routine medical examinations, said Dr. Jimmie C. Holland, who holds the Wayne E. Chapman Chair in Psychiatric Oncology at Memorial Sloan-Kettering Cancer Center, in New York City.

"Can distress become the sixth vital sign?" Holland asked. "I ask this, because we must find a way to incorporate psychological care into total care," she said.

One big problem is that doctors often don't consider the psychological component of total health, and patients are reluctant to bring it up, because they don't want to bother the doctor, Holland said. Part of the barrier comes from the doctor -- "Hey, I'm doing science not touchy-feely stuff. And patients are going to tell me when they're upset," she said, paraphrasing a typical physician.

Holland believes that adding distress to regular evaluations leads to more open communication and encourages treatment; hence, fewer patients will become overly anxious, and there will be fewer patient visits because of worry.

Read more on this topic @ Distress