CMS Finds Overpayment for Antipsychotic Medications

Physicians too often violate federal standards designed to prevent overmedication and inappropriate use of drugs, according to a report by the Office of the Inspector General of the U.S. Department of Health and Human Services.

Testifying before a U.S. Senate panel recently, high-ranking government officials said that in the six months between Jan. 1 and June 30, 2007, 51 percent of the Medicare reimbursement claims for atypical antipsychotic medications were erroneous and cost the program $116 million. The report also found that 83 percent of all reviewed Medicare atypical antipsychotic drug claims for older adults living in nursing homes were for off-label uses. The officials said that more care must be taken to keep physicians from prescribing such medications, although the panel’s chairman noted that the drugs can be beneficial “when properly prescribed,” according to an article published in Health Care Daily Report.

Source: http://www.bna.com/officials-antipsychotic-drug-n12884904634/
Reposted htttp://www.darkestcloset.com

My Plan, My Life, My Psychiatric Advance Directive

Similar to a medical advance directive or a health care power of attorney, a psychiatric advance directive is a legal document completed in a time of wellness that provides instructions regarding treatment or services one wishes to have or not have during a mental health crisis, and may help influence his or her care. A mental health crisis is when a person is unable to make or communicate rational decisions.

A psychiatric advance directive allows you to specify considerations about your mental health care treatment and appoint an agent who may make decisions about your treatment in the event of a mental health crisis. In some cases, you may also give further background information about how you have reacted to past treatment.

Despite these benefits, a survey of mental health experts concluded the underuse of psychiatric advance directives in the United States; this study surveyed 1,011 people with serious mental illness receiving public-sector treatment in 5 cities.

On the My Plan, My Life Web site, you will find comprehensive and easy-to-understand information for individuals with mental illness, their families and health care professionals. On the site you can learn about the importance of psychiatric advance directives as a tool for communicating specifics about one’s care during a mental health crisis and how to prepare your own directive.

My Plan, My Life: My Psychiatric Advance Directive is brought to you by Mental Health America and sponsored by Novartis Pharmaceuticals Corporation. http://www.myplanmylife.com/mylife.cfm

Reposted at darkestcloset.bloggerspot

Deadlines Approach for Four Webinars

Four webinars – on “Demystifying Trauma,” “Working with Voices,” Starting a Peer-Run Respite, and Coalition-Building, respectively – will take place next week! “Demystifying Trauma: Sharing Pathways to Healing and Wellness,” organized by SAMHSA’s ADS Center (Resource Center to Promote Acceptance, Dignity and Social Inclusion Associated with Mental Health), will take place Sept. 26, 2011, 3 p.m. – 4:30 p.m. ET. Registration closes at 5 p.m. ET on Sept. 25. To register, click on the following link: http://promoteacceptance.samhsa.gov/teleconferences/archive/training/teleconference09262011.aspx.

“Working with Voices” will focus on the Hearing Voices Network and Hearing Voices Groups, which do not pathologize hearing voices or other altered experiences. It will take place Sept. 27, 1 p.m. – 2:30 p.m. ET. Space is limited; to register, click here: http://cts.vresp.com/c/?NationalMentalHealth/14baa0ba54/ac1ab23981/db99ce0be4. “So You Want to Start a Peer-Run Respite?” will take place on Sept. 28, 1 p.m. – 2:30 p.m. ET. It the first webinar in a peer-run respite series sponsored by the National Empowerment Center. Space is limited; registration will close on Sept. 27.

To register, click here: https://www3.gotomeeting.com/register/728369694.

“Coalition Building 101 for Mental Health Consumers and Psychiatric Survivors: Finding Common Ground with Each Other and Allies,” to be held Sept. 30, 2:00 p.m. – 3:30 p.m. ET, will include how to address obstacles to sustaining a coalition, action steps to build and/or sustain a coalition, what to do when groups may be competing for the same resources, and more!

To register, e-mail rsvppeerlink@gmail.com with “Coalition Building” in the subject line

 Sources: http://promoteacceptance.samhsa.gov
http://www.nyaprs.org
http://www.power2u.org
SAMHSA/CMHS Consumer Affairs E-News, September 20, 2011

Ethical Concerns in Assertiveness Community Treatment

Author Daniel Farrell is cited in an article featured on the Homelesssness Website and newsletter, in a discussion of ethical concerns about Assertiveness Community Treatment (ACT)

http://homeless.samhsa.gov/Resource/View.aspx?id=52119
Reposted at darkestcloset.bloggerspot

Description: Some critics call Assertive Community Treatment (ACT) a fundamentally coercive model of care because of the level of control that case managers have over their clients’ lives. This article explores some of the resulting ethical concerns of using the ACT model. This article is the third in a series of three articles about ACT.

Embedded in Assertive Community Treatment (ACT) is the element of, well, assertion on the part of service providers. This has led some critics to call ACT a fundamentally coercive model of care. And indeed, many ACT providers find the balance between social control and client independence a very difficult one to strike.

Social Control versus Client Independence

Traditionally, mental health treatment has focused on acting in the best interest of the client. ACT, however, has been accused of being more concerned with benefits to systems instead of individuals. ACT’s community-based approach has its roots in inpatient psychiatric care. Because of this, the idea of patient independence or freedom has been very limited from its earliest beginnings.

These roots can be seen in various forms of social control that are still present in ACT. For instance, ACT staff has the power to force clients into hospitalization, or to remove them from a homeless shelter or drop-in center. They may also demand that clients change their behavior, forcing them to take medication or abstain from alcohol, for instance. If clients do not comply, they may face loss of personal freedom.

ACT staff may also control many other aspects of clients’ lives. They may manage flow of money for clients, their access to doctors and pharmacies, decisions about treatments, and contact with their social networks. The ongoing ethical challenge for ACT staff is to strike a balance. They need to empower clients without neglecting them, care for them without controlling them too much, and give them as much independence as possible even while intervening in their lives.

ACT: A Coercive Model?

It is easy to see how some would perceive coercion to be woven into all aspects of ACT. And it is true that this can happen in many ways. However, some ACT clients are at the extreme end of psychosis. They may suffer a great deal because of their untreated symptoms. Moreover, their experiences may render them unable to understand their illness and their right to humane treatment. In such cases, compassionate coercion may be what allows ACT staff to fulfill their client’s right to this treatment.

It may be helpful to think of coercion on a continuum. At one end is friendly persuasion, in the middle is control of resources, and at the other end of the spectrum is the use of force in treatment. The level of involvement from the case worker depends on many factors, most especially the severity of the case.

What do the critics think?

There are many different players involved in Assertive Community Treatment. Of course, the main players are the clients themselves and their teams of providers, but there is also a diverse community of people who are interested in treatment outcomes.

ACT clients are largely lower-income, rely on public assistance, and have historically had minimal input into their own treatment to begin with. Critics of ACT say treatment that is forced upon individuals is inherently coercive (especially individuals with limited options, as described above). They see this as especially true because a person enrolled in ACT cannot end these services.

Criticism of ACT goes beyond the question of coercion, though. Some doubt the positive outcomes for ACT clients. They argue that the results seen with ACT are not actually all that different from standard treatment, and concerns about the design of studies comparing the two have also been raised.

In addition, critics say that the greatest benefit of ACT (reduced hospitalizations for clients) is not a result of the intervention itself. They see this as simply a part of the design of the model, and administrative distinctions which seek to move clients away from hospitals in general.

What do clients think?

In some ways, it is not surprising that clients themselves did not have a voice in the debate surrounding ACT until decades after the model was developed. But in the mid-1990s, the academic community did start asking clients about their experiences with the program.

Some studies looked at the most important factors in client satisfaction. They found that for clients, these included having consistent contact with staff, supportive services, a positive helping alliance, and a sense of trust and caring by ACT staff. Other studies found that clients enrolled in ACT were happy with housing assistance and the help they received in adjusting to their communities.

The feedback wasn’t all positive, though. One study found that even though clients were satisfied with many aspects of care, they were not happy with medication and treatment issues. Clients in another study said they disliked what they saw as “program intrusiveness.” They felt that the program was too confining and echoed earlier sentiments that there was too much of a focus on medication compliance.

In the end, the question of coercion in ACT may be largely a matter of opinion. But what is less subjective is the issue of balance, as service providers are pulled between control over and independence for their clients.

Read the first two articles in the series: All About Assertive Community Treatment (ACT),  Assertive Community Treatment (ACT) for People Experiencing Homelessness

 

 

"An Anatomy of Addiction": Sigmund Freud, cokehead How a "wonder drug" shaped the birth of psychoanalysis and modern surgery

Sunday, Jul 17, 2011 19:01 ET  Reposted at darkestcloset.blogspot.com     By Laura Miller

Published at WIkipedia/Salon

Nicholas Meyer's bestselling 1974 novel, "The Seven Percent Solution," isn't mentioned once in "An Anatomy of Addiction: Sigmund Freud, William Halsted and the Miracle Drug Cocaine" by Howard Markel, but any of Markel's readers who have also read Meyer's highly entertaining Sherlock Holmes pastiche will think of it often all the same. The novel "reveals" that Holmes' "Great Hiatus" (the three years between his false death at Reichenbach Falls and his reappearance in "The Adventure of the Empty House") was actually a period of recovery from cocaine addiction after his treatment by the great Viennese therapist Sigmund Freud. The founder of psychoanalysis brought exceptional insight to bear in providing this cure; he once abused cocaine himself.

Markel's provocative book is a dual addiction biography of Freud and his contemporary, William Halsted, arguably the greatest surgeon of his time, a founding professor at Johns Hopkins Hospital and deviser of at least a half-dozen revolutionary surgical techniques and procedures still employed today, such as the use of rubber gloves. Both were unquestionably great men, but they also wrestled with dangerous drug habits that imperiled their work. Both sought to conceal or downplay their drug use and, as a result, information on that use and how, if at all, they managed to stop it is pretty sparse on the ground. If Meyer's novel is the story of a doctor investigating the psyche of a great detective, then "An Anatomy of Addiction" is the work of a doctor -- Markel is an M.D. and director for the Center of the History of Medicine at the University of Michigan -- who plays detective to understand the secret lives of two medical giants.

Halsted and Freud never met, and came from very different backgrounds, but they were both ambitious and energetic young doctors in the 1880s, when cocaine was being celebrated as a new wonder drug whose full potential had yet to be explored. In Austria, Freud wrote a prominent paper touting the newly isolated alkaloid as a treatment for morphine and opium addiction. He tested it on a close friend who had become hooked on the morphine he used to manage a chronic injury.

What Freud missed, and what became the drug's chief medical use for the next decade or so, was cocaine's value as a local anesthetic. Halsted, an indefatigable and daring young surgeon (he successfully removed his own mother's gall bladder on the family's kitchen table at 2 a.m., with his untrained father and siblings attending), was as eager to explore its possibilities as he was to adopt the new antiseptic protocols advocated by Joseph Lister. Like many doctors of the time, including Freud, he tested the drug's properties on himself, his colleagues and his students. "In a matter of weeks," Markel writes, "Halsted and his immediate circle transformed from an elite cadre of doctors into active cocaine abusers."

Halsted shot up; Freud snorted. Halsted was rich and well connected; Freud was close to broke and struggling to make a name for himself in a profession afflicted by expanding pockets of anti-Semitism. Freud by all accounts figured out how to give up the drug, while Halsted, Markel believes, would go on occasional binges throughout the rest of his distinguished life. At least twice, Halsted resorted to staying at a Rhode Island sanitarium to get clean. He also used morphine, probably daily. Behavior that many of his students and colleagues shrugged off as eccentricity -- lateness, incommunicado periods, a refusal to look people in the eyes (and thereby reveal his dilated pupils) -- were read by a handful of astute observers as signs that the drug use he'd supposedly abandoned before arriving at Hopkins was still going on.

Freud, on the other hand, seems to have entirely stopped using cocaine by the turn of the century. For the rest of his days he strove to downplay the effect it had on his life and work. Markel will have none of this, arguing that cocaine played a major role in Freud's friendship with Wilhelm Fliess, a general practitioner who espoused the crackpot theory that many physical and emotional problems could be cured by intensive surgery to the nose (with liberal applications of cocaine). Freud recommended one of his own patients to Fliess, who proceeded to disfigure and nearly kill the young woman in a case of flagrant malpractice. Freud made excuses for him.

The Fliess affair seems less a case of cocaine-induced incompetence than an example of Freud's propensity for stubbornly idealizing a particular friend to the point of delusion. Similarly, it took him far too long to admit he had understated the dangers of cocaine, even after he'd witnessed its eventual, disastrous effect on his morphine-addicted friend. All discussions of Freud are further complicated by the fact that the brilliance of his ideas and his writings was not mirrored in his therapeutic success rate. He was a major thinker, but an indifferent doctor. Far better to be his student than his patient.

For the most part, however, "An Anatomy of Addiction" is persuasive and engrossing. Markel is especially good at capturing the hierarchical, ultra-competitive, pressurized world of 19th-century medicine, with its revered masters and mentors presiding over students and young doctors desperately striving to make an impression and a reputation. Perceptively, he traces the birth of psychoanalysis to Freud's use of himself as an experimental subject in documenting the effects of cocaine. For the first time, Freud "incorporates his own feelings, sensations and experiences into his scientific observations."

Freud was always at his best when contemplating the subject of his own psyche. (His weaknesses, furthermore, often spring from a tendency to overgeneralize from it.) If his cocaine experiments nudged him in that direction, then perhaps we do owe some of the most influential ideas of the last century to the influence of Bolivian Marching Powder. More's the pity, then, that pride or fear or something else kept Freud from recounting how he kicked the habit.

An Anatomy of Addiction

by Howard Markel

 

Laura Miller is a senior writer for Salon. She is the author of "The Magician's Book: A Skeptic's Adventures in Narnia" and has a Web site, magiciansbook.com. More: Laura Miller