Posts tagged apa
Posts tagged apa
Psychiatry a Key Player in Effective Health Reform, APA Says
By Megan Brooks, Medscape
An American Psychiatric Association (APA) work group on healthcare reform outlines key issues facing the field of psychiatry and offers recommendations for action in a report released today.
"Throughout this recent period of change, the focus on behavioral health, which includes mental illnesses and substance use disorders, has begun to shift from a compartmentalized provider approach to an integrated delivery system linking behavioral health and primary care services. This has led to a renewed awareness that mental health is critical to overall health and wellbeing," the report notes.
The work group was established by the APA board of trustees and chaired by Paul Summergrad, MD, chair of the Department of Psychiatry at Tufts University School of Medicine, Boston, Massachusetts, and president-elect of the APA. The group met numerous times during an 18-month period with input from the board of trustees, the assembly, and relevant councils and components.
Critical Role for Psychiatrists
According to the report, as healthcare reform expands insurance coverage and extends parity of benefits for behavioral health needs, it will be “critical to monitor new developments, models of care, and payment methodologies, and to enforce compliance to ensure patients and families receive the best quality of care.”
"Psychiatry must play a central role in the new patient care and delivery and payment models. These models must include an expanded emphasis on behavioral health," the report says.
The report also notes that integrated care models “hold promise” in addressing many of the challenges facing the healthcare system, but “more research is needed to build their evidence base, explore their financial impact and define the role of psychiatrists, primary care providers and other behavioral health providers.”
"Psychiatrists, alongside primary care providers, must play a major role in formulating integrated care solutions by defining their role and benefit to patients," the report recommends. It encourages the National Institutes of Health, the Centers for Medicare and Medicaid Services, and other federal agencies to continue their ongoing research and evaluation of these models.
The work group also tackled issues of financing of psychiatric care, concluding that fundamental payment issues, including implementation of parity laws, “must be addressed” to achieve the coverage, access, and new care delivery goals of the Affordable Care Act. This includes the economic impact of integration, Medicaid reimbursement policies, Medicare fee schedule distortions, fee for service payment methodologies, and the structure and management of payment.
IT Challenges Ahead
They conclude that payer and systems’ budgeting mechanisms must include management of psychiatric care within the broader medical healthcare budgets, while protecting core services for those with mental illnesses.
On the subject of quality performance and measurement, the group notes that healthcare reform has accelerated the development and use of performance indicators and recommends that the behavioral health field “become more fully engaged in the development of performance measures.”
"The field must lead on quality metrics for psychiatric care and their consistent adoption across payers and other regulatory entities. This can be accomplished by identifying a few priority areas for improvement, as well as establishing a series of goals covering various areas of practice," the group advises.
On health information technology (HIT), the group says several “challenges” lie ahead in the behavioral health field. The success of integrated care models is particularly dependent upon the deployment of electronic health records and patient registries, the report says.
The report concludes that HIT “should be a priority focus of communication and education for the psychiatric field, healthcare providers in general, patients, policy makers and the public.”
The report also addresses workforce, work environment, and medical education and training. Its key finding: “Without changes in the workforce, the field will have difficulty meeting the increased demand for specialty psychiatric physician services. Curriculum, accreditation standards, new Continuing Medical Education (CME) trainings and collaboration with primary care practitioners are needed to meet newly insured patient needs as well as provide for new care delivery models.”
The recommendations of the work group “serve as a springboard for discussion and action within the field of psychiatry,” the authors say.
APA. Integrated Care. Full article
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The Selling of Attention Deficit Disorder
By Alan Schwartz
The Number of Diagnoses Soared Amid a 20-Year Drug Marketing Campaign
Excerpt: After more than 50 years leading the fight to legitimize attention deficit hyperactivity disorder, Keith Conners could be celebrating.
Severely hyperactive and impulsive children, once shunned as bad seeds, are now recognized as having a real neurological problem. Doctors and parents have largely accepted drugs like Adderall and Concerta to temper the traits of classic A.D.H.D., helping youngsters succeed in school and beyond.
But Dr. Conners did not feel triumphant this fall as he addressed a group of fellow A.D.H.D. specialists in Washington. He noted that recent data from the Centers for Disease Control and Prevention show that the diagnosis had been made in 15 percent of high school-age children, and that the number of children on medication for the disorder had soared to 3.5 million from 600,000 in 1990. He questioned the rising rates of diagnosis and called them “a national disaster of dangerous proportions.”
“The numbers make it look like an epidemic. Well, it’s not. It’s preposterous,” Dr. Conners, a psychologist and professor emeritus at Duke University, said in a subsequent interview. “This is a concoction to justify the giving out of medication at unprecedented and unjustifiable levels.”
The rise of A.D.H.D. diagnoses and prescriptions for stimulants over the years coincided with a remarkably successful two-decade campaign by pharmaceutical companies to publicize the syndrome and promote the pills to doctors, educators and parents. With the children’s market booming, the industry is now employing similar marketing techniques as it focuses on adult A.D.H.D., which could become even more profitable.
Few dispute that classic A.D.H.D., historically estimated to affect 5 percent of children, is a legitimate disability that impedes success at school, work and personal life. Medication often assuages the severe impulsiveness and inability to concentrate, allowing a person’s underlying drive and intelligence to emerge.
But even some of the field’s longtime advocates say the zeal to find and treat every A.D.H.D. child has led to too many people with scant symptoms receiving the diagnosis and medication. The disorder is now the second most frequent long-term diagnosis made in children, narrowly trailing asthma, according to a New York Times analysis of C.D.C. data.
Behind that growth has been drug company marketing that has stretched the image of classic A.D.H.D. to include relatively normal behavior like carelessness and impatience, and has often overstated the pills’ benefits. Advertising on television and in popular magazines like People and Good Housekeeping has cast common childhood forgetfulness and poor grades as grounds for medication that, among other benefits, can result in “schoolwork that matches his intelligence” and ease family tension.
A 2002 ad for Adderall showed a mother playing with her son and saying, “Thanks for taking out the garbage.”
The Food and Drug Administration has cited every major A.D.H.D. drug — stimulants like Adderall, Concerta, Focalin and Vyvanse, and nonstimulants like Intuniv and Strattera — for false and misleading advertising since 2000, some multiple times.
Sources of information that would seem neutral also delivered messages from the pharmaceutical industry. Doctors paid by drug companies have published research and delivered presentations that encourage physicians to make diagnoses more often that discredit growing concerns about overdiagnosis.
Many doctors have portrayed the medications as benign — “safer than aspirin,” some say — even though they can have significant side effects and are regulated in the same class as morphine and oxycodone because of their potential for abuse and addiction. Patient advocacy groups tried to get the government to loosen regulation of stimulants while having sizable portions of their operating budgets covered by pharmaceutical interests.
Companies even try to speak to youngsters directly. Shire — the longtime market leader, with several A.D.H.D. medications including Adderall — recently subsidized 50,000 copies of a comic book that tries to demystify the disorder and uses superheroes to tell children, “Medicines may make it easier to pay attention and control your behavior!”
Profits for the A.D.H.D. drug industry have soared. Sales of stimulant medication in 2012 were nearly $9 billion, more than five times the $1.7 billion a decade before, according to the data company IMS Health.
Even Roger Griggs, the pharmaceutical executive who introduced Adderall in 1994, said he strongly opposes marketing stimulants to the general public because of their dangers. He calls them “nuclear bombs,” warranted only under extreme circumstances and when carefully overseen by a physician.
Psychiatric breakdown and suicidal thoughts are the most rare and extreme results of stimulant addiction, but those horror stories are far outnumbered by people who, seeking to study or work longer hours, cannot sleep for days, lose their appetite or hallucinate. More can simply become habituated to the pills and feel they cannot cope without them.
Tom Casola, the Shire vice president who oversees the A.D.H.D. division, said in an interview that the company aims to provide effective treatment for those with the disorder, and that ultimately doctors were responsible for proper evaluations and prescriptions. He added that he understood some of the concerns voiced by the Food and Drug Administration and others about aggressive ads, and said that materials that run afoul of guidelines are replaced.
“Shire — and I think the vast majority of pharmaceutical companies — intend to market in a way that’s responsible and in a way that is compliant with the regulations,” Mr. Casola said. “Again, I like to think we come at it from a higher order. We are dealing with patients’ health.”
A spokesman for Janssen Pharmaceuticals, which makes Concerta, said in an email, “Over the years, we worked with clinicians, parents and advocacy groups to help educate health care practitioners and caregivers about diagnosis and treatment of A.D.H.D., including safe and effective use of medication.”
Now targeting adults, Shire and two patient advocacy groups have recruited celebrities like the Maroon 5 musician Adam Levine for their marketing campaign, “It’s Your A.D.H.D. – Own It.” Online quizzes sponsored by drug companies are designed to encourage people to pursue treatment. A medical education video sponsored by Shire portrays a physician making a diagnosis of the disorder in an adult in a six-minute conversation, after which the doctor recommends medication.
Like most psychiatric conditions, A.D.H.D. has no definitive test, and most experts in the field agree that its symptoms are open to interpretation by patients, parents and doctors. The American Psychiatric Association, which receives significant financing from drug companies, has gradually loosened the official criteria for the disorder to include common childhood behavior like “makes careless mistakes” or “often has difficulty waiting his or her turn.”
The idea that a pill might ease troubles and tension has proved seductive to worried parents, rushed doctors and others.
“Pharma pushed as far as they could, but you can’t just blame the virus,” said Dr. Lawrence Diller, a behavioral pediatrician in Walnut Creek, Calif. “You have to have a susceptible host for the epidemic to take hold. There’s something they know about us that they utilize and exploit.”
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A soon-to-be-released documentary feature, Kings Park offers an inside look at public mental health care in America by focusing on the story of this now abandoned institution. The journey back begins with Lucy’s sudden decision, on the cusp of her fiftieth birthday, to return to Kings Park for the first time in over thirty years. Determined to face her past and come to terms with her commitment to the state hospital, Lucy’s goals are purely personal when the film begins. She soon learns, however, that in order to fully understand her own story, she needs to somehow learn about the institutional world in which she was once locked away. To this end, Lucy seeks out other former patients, their families, and hospital staff, who share intimate accounts of life at Kings Park. Shot on the overgrown and sprawling grounds of the shuttered hospital, these firsthand accounts of a vanishing world bear witness to the many changes in treatment, policy and attitudes over the past century.
The film culminates with a vision of today. Stories are shared of the often brutally executed “emptying out” of the hospital, and we follow Lucy in her effort to see how mental health care has changed since the hospital’s close. Scenes shot at small mental health care centers, committed to the recovery of their members despite limited resources, let us see the kind of progress that is being made. In contrast, footage shot at the local jail reveals a very different reality – where the penal system has replaced the state hospital as the default “provider” for people with serious mental illness.
By Robert D. Stolorow, Ph.D. for Psychology Today
A young woman who had been repeatedly sexually abused by her father when she was a child began psychotherapy with a young female therapist who consulted with me on the case. Early in the treatment, whenever the patient began to remember and describe the sexual abuse, or to recount analogously invasive experiences in her current life, she would display emotional reactions that consisted of two distinctive parts, both of which seemed entirely bodily. One was a trembling in her arms and upper torso, which sometimes escalated into violent shaking. The other was an intense flushing of her face. On these occasions, the therapist was quite alarmed by her patient’s shaking and was concerned to find some way to calm her.
I had a hunch that the shaking was a bodily manifestation of a traumatized state and that the flushing was a somatic form of the patient’s shame about exposing this state to her therapist, and I suggested to the therapist that she focus her inquiries on the flushing rather than the shaking. As a result of this shift in focus, the patient began to speak about how she believed her therapist viewed her when she was trembling or shaking: surely her therapist must be regarding her with disdain, seeing her as a damaged mess of a human being. As this belief was repeatedly disconfirmed by her therapist’s responding with emotional understanding rather than contempt, both the flushing and the shaking diminished in intensity. The traumatized states actually underwent a process of transformation from being exclusively bodily states into ones in which the bodily sensations came to be united with words. Instead of only shaking, the patient began to speak about her terror of annihilating intrusion.
The one and only time the patient had attempted to speak to her mother about the sexual abuse, her mother shamed her severely, declaring her to be a wicked little girl for making up such lies about her father. Thereafter, the patient did not tell any other human being about her trauma until she revealed it to her therapist, and both the flushing of her face and the restriction of her experience of terror to its nameless bodily component were heir to her mother’s shaming. Only with a shift in her perception of her therapist from one in which her therapist was potentially or secretly shaming to one in which she was accepting and understanding could the patient’s emotional experience of her traumatized states shift from an exclusively bodily form to an experience that could be felt and named as terror. It is in the formation of such somatic-linguistic unities, the bringing of emotional experience into language within a holding context of human understanding, that a sense of being can be born, restored, or consolidated.
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