The Practical Psychiatrist News and Information

The Atlanta Journal  Constitution reported yesterday that the State of Georgia is on the fast-track for privatization of its entire mental health system. As in most states, the motivation is financial. The state's mental health system is underfunded, incidents of abuse and negelct and abuse leading to patient deaths in the system have recently been publicized (see recent article from AJC,Hidden Shame), and the state is unwilling or unable to provide adequate funding to the system. Folks in the state goverment feel that a private entity will be able to run the system in a more efficient and cost effective manner than the state. What puzzles me about this plan is the intent of the state to turn over the ENTIRE management of the system to this private entity. Why do these sorts of changes have to be wholesale. Undertaking such a task would require a massive amount of planning to execute but this plan is slated to be completed by 2012. The reviews have been "mixed" thus far in states that have attempted only  partial transfers of of this sort.

Genetic Research Provides Insight To Possible Causes of Mental Illness

Psychiatry is not an exact science. Other than a very rough idea of the chemicals in the brain (neurotransmitters) which may be associated with mental illness, we have no objective understanding of the factors which lead to mental illness. For example, we know that the neurotransmitters serotonin, norepinephrine, and dopamine seem to have an effect on mood, and that abnormalities in the levels of these chemicals in certain areas of the brain may lead to mood disorders. Beyond that, we know very little.

Why is it that different people experience different symptoms when they are depressed? Why do some people sleep too much while others sleep too little? Why do some folks have increased appetite while others have reduced appetite. Why do some people have a lot of anxiety when they are depressed while others don't.

Why might a person respond to one medication in a specific antidepressant class and not respond to another in the same class. As a psychiatrist, I see people who respond very well to sertraline, but if the medication is changed for some reason, they don't respond as well or even at all to paroxetine. Sertraline (Zoloft) and paroxetine (Paxil, Pexeva) are both selective serotonin reuptake inhibitors (SSRIs). These medications seem to work by increasing the amount of serotonin surrounding specific nerve cells (neurons) in the brain. Serotonin may help improve mood by interacting with proteins (receptors) on the outside of the neuron.They do this by preventing the uptake of the serotonin back into the neuron so that there is more available to be used by the outside of the cell. Since sertraline and paroxetine are both block the reuptake of serotonin, why wouldn't a person respond similarly to either medication?

Recently advances in genetic research are revealing how very complex the causes of mental illness may be.

From Goldberg, 10/14/08, Boston Globe

"Dr. Thomas Insel, director of the National Institute of Mental Health, compares psychiatric genetics to a 1,000-piece jigsaw puzzle, in which researchers have just started to fit together a few edge pieces.

But "this is unprecedented progress," he said. "This is a time of real excitement in a field that up until now hasn't given us much to cheer about."

The findings, including major work published by Boston-area scientists, suggest that although mental illness is known to run in families, it may sometimes stem not from inherited defects but from spontaneous mutations that occur during earliest development in the womb.

Researchers are also finding some apparent genetic links between dramatically different disorders. For example, a genetic glitch previously shown to raise the risk of schizophrenia is also linked to autism and mental retardation, a study in the New England Journal of Medicine reported last month (NEJM Sept).

Dr. Edward Scolnick, director of the Broad Institute's Stanley Center for Psychiatric Resarch in Cambridge, has found himself telling people of late that the field of psychiatric genetics has "crossed the Mississippi."

"To explore the West, it will take a lot of work, and a lot of money," he said, arguing that the field needs an additional $200 million or more to quickly unravel the basic "genetic architecture" of severe mental illness. "There is a lot left to do. But we know how to go about it now."

This is an exciting time to be a psychiatrist. I believe that after centuries of blindly searching for answers to the causes of mental illness, we have finally started unraveling the mystery.

Task force recommends changes to state's involuntary commitment laws

Recently, people with mental illness have perpetrated several "high profile" violent crimes. On April  16th, 2007, Seung Hui Cho, a young man previously diagnosed with anxiety and major depression, killed 32 people during a shooting rampage on the campus of Virginia Technical College. On December the 8th of that same year Robert A. Hawkins, who spent his early years as a ward of the state, and had been diagnosed with major depression and attention deficit hyperactivity disorder, killed 8 people in a mall in Omaha, Nebraska. States, cities, and communities have reacted in different ways in the wake of these tragedies (see the Virginia Tech Review Panel Report as an example.)

On December 31st, 2007 in Seattle, WA, James Williams, a man who had been diagnosed with schizophrenia and had a history of violence, attacked and killed Shannon Harps. Mr. Williams was under court ordered supervision at the time but had violated the court order by stopping his psychiatric medications. After the murder, a diverse panel of community members and leaders, law enforcement professionals, and mental health professionals, met to develop recommendations for improving the mental health system and potentially preventing a similar incident in the future. Carol Smith, 10/9/08 seattlepi.com reported on the findings of the panel and its recommendations.

"A mental health system facing a critical shortage of hospital beds, riddled with breakdowns in communication and hamstrung by the state's commitment laws helped create the conditions that led to the killing of Sierra Club worker Shannon Harps outside her Capitol Hill apartment last New Year's Eve, a task force reviewing how the system operated in that case has found."

You could apply this statement to just about any community in America, urban or rural. The problem is complex. Nationally, long term psychiatric beds have been gradually cut over the last few decades to deal, usually by court order,  with the overcrowding, treatment inadequacy, and patient abuses associated with the Asylum model of psychiatric care. Corresponding development of community psychiatric care programs to replace the long term beds has lagged due to a failure by federal and state goverments to shift or even provide funding for the systemic changes. As this process has evolved, it has become apparent that some patients require more structure and support than previously anticipated by the court systems in order to acheive or maintain their recovery from their mental illness.

Communication between different community providers is often poor. Barriers to communication are numerous. The process of deinstitutionalization has occurred in a piece-meal fashion with no coherent development of services (since there has never been a coherent plan!). Within a single community, both state and private entities provide services for mentally ill patients. Internal turf battles arise between state agencies which provide duplicate care for the same population. Private and public agencies have difficulty communicating. Federal privacy laws and regulations are confusing and many providers take an attitude of "better safe than sorry" (meaning, in this case, that it is better NOT to release information on a psychiatric patient if the provider is unsure about the circumstances for which they are requested).

Other recommendations include:

"One of the biggest reforms would be to change the state's involuntary commitment laws to mandate treatment for those with a significant history of violence, the Seattle P-I has learned." Who would decide sort of history of violence mandates treatment? How long would the treatment be mandated? Who would pay for the treatment?

"Providing more tools for enforcing outpatient treatment in the community." Currently, the only tool we have for enforcing outpatient commitment in Birmingham is the threat of inpatient commitment. 

"Reducing privacy barriers so police can know the mental health histories of people they deal with in "real time." This is the recommendation that makes me uncomfortable. It's one thing to allow freer communication between caregivers, but quite another to extend that access to information to law enforcement.

"Allowing those who make involuntary treatment decisions more leeway to consider past history of violence." Numerous studies have shown that a history of violence predicts future violence. I believe that if involuntary treatment is being considered for an individual patient, a history of violence should be a consideration in whether or not that person is committed to involuntary treatment.

"Other proposals emerging from the task force include allowing juries a new option of "guilty but mentally ill" in addition to "not guilty by reason of insanity."I have been involved in several cases where patients committed crimes while mentally ill, but had made a conscious decision to be non-compliant with medications prior to the commission of the crime. Though their mental illness played a role in the commission of the crime, their decision to be non-compliant with treatment was what set the ball rolling. Should the patient be held accountable for this factor?

Diabetes and Depression; Deadly Combination

In a study published in the October Journal of General Internal Medicine, Katon, et. al. determined that in a large (10,704) cohort of patients with diabetes, comorbid depression was associated with an increase in all cause mortality over a two year period. Notably, there was a 36-38% increase in the risk of mortality, depending on what definition of depression was used.

More evidence that the combination of physical and psychiatric illness may be deadlier than physical illness alone.

America's Health Starts With Healthy Children: How Do States Compare

"How Do States Compare?, examines the health of children from different socioeconomic backgrounds in every state to document how healthy our nation's children are now and how healthy they could be if we as a nation were realizing our full health potential. How Do States Compare?, examines the health of children from different socioeconomic backgrounds in every state to document how healthy our nation's children are now and how healthy they could be if we as a nation were realizing our full health potential."

I hate to give away the ending, but if you are a child who is non-hispanic, white, and upper income, living in a non-southern or non-western state, and whose parents are well educated, you shouldn't worry too much. Otherwise...

A link to the Robert Wood Johnson Report

Webinar: Law Enforcement and People with Mental Illnesses

This sounds like an excellent opportunity for members of the law enforcement profession to gain knowledge about dealing with people who have mental illness. People with severe and persistent mental illness have a higher liklihood of coming into contact with the criminal justice system for a variety of reasons. With de-institutionalization of the seriously and persistently mentally ill and a shortage of acute inpatient psychiatric beds and residential treatment opitions, the population of mentally ill jail and prison inmates has increased dramatically. Historically, the law enforcement profession and professionals within the mental health system have communicated poorly. This state of affairs is no longer an option. Please take a look at this "webinar" and see if it might be something that would benefit your community.

Webinar: Law Enforcement and People with Mental Illnesses Free: Space is Limited! Tuesday, October 28, 2008, 2:00 PM Eastern Time Duration: Approximately One Hour with Q and A Brought to you by National Council for Community Behavioral Healthcare Council of State Governments Justice Center, with support from the Bureau of Justice Assistance, U.S. Department of Justice Presenters Captain Richard Wall, Los Angeles Police Department; Fred Osher, M.D., Director of Health Systems and Services Policy, CSG Justice Center; Melissa Reuland, Senior Research Consultant, Police Executive Research Forum About the Webinar Law enforcement officers regularly respond to calls that involve people with mental illnesses. On rare but highly publicized occasions, these incidents result in injury or death for the individual, officer, or others at the scene. More often, officers spend long periods of time on these complex calls for service only to see the person cycling through the criminal justice system without any positive long-term effect. On this webinar, national experts in law enforcement and mental health will discuss effective crisis response models. They will outline how community behavioral health care providers and law enforcement can collaborate and tailor responses to the problems of their jurisdiction. The webinar spotlights Improving Responses to People with Mental Illnesses: The Essential Elements of a Specialized Law Enforcement-Based Program, a report supported by the Bureau of Justice Assistance, U.S. Department of Justice. Written by the Council of State Governments Justice Center and the Police Executive Research Forum, it highlights 10 key components for improving officers' encounters with individuals with mental illnesses. Quick Registration Registration is free but is limited to the first 1,000 registrants. To register, go to http://www2.eventsvc.com/nationalcouncil/, select the law enforcement/mental health event, and enter the coupon code COUNCIL at checkout. If registering for a webinar for the first time, create a profile with the email and password of your choice. A confirmation with webinar access information will be sent to the email address you enter. Participation will require Internet access and a phone line. Participants from the same location are encouraged to use a single phone line - one individual may register and get access information for the whole group. Questions? Contact Communications@thenationalcouncil or call 301.984.6200. More About the Presenters Captain Richard Wall, Los Angeles Police Department Captain Wall currently commands the Central Patrol Division, an area encompassing downtown Los Angeles and the "skid row" area. Formerly, Captain Wall was the Project Manager for the department's Mental Illness Projects, tasked with identifying, developing, and implementing "best practices" for law enforcement responses to people with mental illnesses. Fred Osher, M.D., Director of Health Systems and Services Policy, CSG Justice Center Dr. Osher oversees the health components of the CSG Justice Center's initiatives. He has published extensively on community psychiatry, co-occurring mental and addictive disorders, and effective approaches to persons with behavioral disorders under criminal justice supervision. Melissa Reuland, Senior Research Consultant, Police Executive Research Forum Ms. Reuland is a researcher and co-author of Improving Responses to People with Mental Illnesses: The Essential Elements of a Specialized Law Enforcement-Based Program. She has worked with Justice Center staff on products and TA to expand specialized law enforcement responses in cities across the nation. The Council of State Governments Justice Center is a national nonprofit organization that serves policymakers at the local, state, and federal levels from all branches of government. It provides practical, nonpartisan advice and consensus-driven strategies-informed by available evidence-to increase public safety and strengthen communities. www.justicecenter.csg.org

Experts Testify Pfizer Manipulated Negative Research Findings To Promote Off-label Use Of Neurontin

In today's New York Times, Stephanie Saul reports; "The drug maker Pfizer earlier this decade manipulated the publication of scientific studies to bolster the use of its epilepsy drug Neurontin for other disorders, while suppressing research that did not support those uses, according to experts who reviewed thousands of company documents for plaintiffs in a lawsuit against the company."

Pfizer acquired Warner Lambert (W/L) in 2000. W/L had marketed Neurontin throughout the 1990's. In 2004, the patents for Neurontin expired and Pfizer ceased marketing the drug. That same year, Pfizer paid a $430 million settlement for claims related to inappropriate marketing of Neurontin in the 1990's by W/L. (Sales of Neurontin approached $3 billion/year up to 2004 when its patent expired. According to my calculations, 430 million is about 0.00014% of 3 billion.)

Pfizer has maintained that the company changed marketing policies in 2000 when W/L was acquired, but specific evidence presented in the trial suggests that in 2000, Pfizer marketing managers were working with scientific writers to present "negative" studies in such a way as to make them appear to be "positive". That is, making studies which might indicate the medication would not be useful for a particular disorder appear to indicate that it IS useful for the disorder. Other evidence indicates that Pfizer attempted to delay the release of negative studies, or attempted to bury negative findings in papers covering multiple studies in order to camouflage the results.

A Guide to Substance Abuse Services for Primary Care Clinicians: Concise Desk Reference

Alcohol and drug abuse are major causes of morbidity and mortality in the United States. With the multitude of injuries and health complications associated with substance use disorders ( occurring in all age groups), primary care providers are in an opportune position to provide early intervention for patients suffering with substance related illnesses.

The Substance Abuse and Mental Health Services (a division of the US Department of Health and Human Services) publishes Treatment Improvement Protocols as part of their mission to improve treatment of substance use disorders by providing best practice guidelines to clinicians, program administrators, and payees. This purpose of this publication, TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians, is to help physicians, nurses, physician assistants, and advanced practice nurses screen their patients for substance use disorders, conduct brief interventions for patients in the early stages of their illness, and refer more severely affected patients for in-depth assessment and treatment. TIP 24 also gives an overview of the types of treatment available and outlines a primary care clinician’s role in aftercare.

TIP 24 has a good review of the indications of substance abuse, choosing appropriate screening and assessment instruments, how to discuss this subject with your patient. On page 3 of this document is an algorithm which gives the “patient flow through primary care and referral”. There is also a section on how to perform an office-based intervention in which you and your patient set mutually agreed upon goals and set up a “contract” for your patient to stop or cut back on alcohol or other drug use.

You can download this .pdf publication for free at http://ncadistore.samhsa.gov/catalog/productDetails.aspx?ProductID=17867 . Take a moment to download it and look through it. You may want to distribute it throughout your office for clinical and support staff, since it contains simple screening tools that anyone can use for screening purposes.

Faye, Gustav, and Ike - Relief and Mental Health Resources

With the recent hurricanes, I wanted to update my list of disaster/hurricane relief and mental health resources.

Federal Programs

• Federal Emergency Management Agency (FEMA) apply for assistance, disaster information
• Personal and Family Disaster Preparedness
• National Hurricane Center from the National Weather Service
• Hurricane's Ahead! - For Kids- Owlie Skywarn's Weather Book
• American Red Cross disaster services
• SAMHSA's Disaster Technical Assistance Center
• Education and Training Materials for Providing Mental Health Services During Disasters
• American Psychiatric Association's Website for Disaster Psychiatry

 

Programs By State

Texas

• State Mental Health Resources for Texas
• Governors Division of Emergency Management
• State Hurricane Awareness Center

Mississippi

• Mississippi Mental Health Services   
• Mississippi Emergency Management Agency (MEMA)
• Disaster Assistance Information from MEMA's Site

Alabama

• Alabama Mental Health Services
• Alabama Emergency Management Agency
• Local Emergency Management Offices
• Alabama EMA Kids Page - It truly does my heart good to see that my own home state has taken the interests of children affected by disaster (or who are learning about disasters) into consideration and created a page just for them!

Florida   

• Florida Mental Health Services
• Florida Division of Emergency Managment homepage   
• Florida's State Emergency Response Team
  

Georgia

• Georga Mental Health Services
• Georgia Emergency Management Agency
• Assistance Page of Georgia EMA

South Carolina

• South Carolina Mental Health Services
• South Carolina Emergency Management Division
• Hurricane Hanna News Re