Thursday, December 12, 2013

For Elites Only: Half Of Psychiatrists Won't Take Health Insurance

For Elites Only: Half Of Psychiatrists Won't Take Health Insurance

As a solo practitioner I can make comments here. The issue really is time. Mental status exams are the only tool I have to make a diagnosis and start a treatment plan. There are no tests that I can do that tell me it's depression or schizophrenia. A large portion of this exam is based on history which is difficult to illicit particularly if someone is having a hard time thinking and recalling information. These evaluations take about an hour of time. Then I have to consent for the medications, which takes more time. Follow up exams take at least 20 minutes to assess if everything I started is working or if there is something else that I need to focus on that was missed. A primary care doctor can look at labs, make a diagnosis and finish with a patient in 10 minutes. My husband, a physician has told me that when he walks into the hospital to see a patient, he picks up the chart, looks at labs, makes a diagnosis, develops the treatment plan and by the time he walks into the patient's room can say "hello" to the patient, state what's wrong, what he is going to do and leave; all within about 7 minutes. It takes him 5 minutes to complete the chart paperwork. This would be impossible in a psychiatry practice.

Insurance companies particularly government insurance DOES NOT PAY enough for me to run a business and cover my ass for malpractice. If  I don't spend enough time, due diligence; I run the risk of a malpractice law suit, a law suit where the insurance (Medicaid) only paid about $40 for that visit. 

In my office I have a biller that submits claims to my patient's insurance. The insurance company then sends what it would pay me to the patient instead. Most of my patients find this acceptable. Medicare and Medicaid makes this kind of reimbursement to the patient virtually impossible.

A real solution here could be to use physician extenders particularly in the outpatient setting. There is the available psychiatrist who has several physician assistants or nurse practitioners presenting cases and after discussion with the psychiatrist goes back to the patient to implement treatment plans. This is the model we use in residency training programs. Patients not responding to treatment would be seen by the psychiatrist. Psychiatrists for this oversight are paid hourly and physician extenders are paid based on their level of training which is less and more cost effective. Patients who want to see the psychiatrist would have to pay accordingly. This would serve the greatest number for the least cost and could raise the baseline of mental health care in this country. The time efficiency would also decrease wait time for continued treatment appointments. The under served could greatly benefit as well.

I agree there is a mental health crisis. We should begin by talking to psychiatrists first.

Saturday, November 9, 2013

Bipolar Disorder, It's a Mood Thang.

Bipolar Spectrum Disorder is one of the most fascinating diseases that I treat. In my practice, I don't usually see the flagrant disease presentations anymore. That was something that I saw more often during my residency and hospital training. What I see now is mostly older adults in their 30's and 40's, who have noticed that they keep suffering even after satisfactory psychiatric treatment in the past. These are usually patients who tell me they have depression episodes that keep coming back for no reason. Their lives are fine, and there is no real stress to account for the symptoms. They often present not looking that depressed, have trouble with sleeping and are also angry and irritable. There is a history of suicidal thoughts that come out of no where and then disappear. Most of these patients tell me the antidepressants they have been prescribed don't seem to work.

Treatment resistant depression that keeps coming back is probably Bipolar II disorder. In fact there are enough variations on the theme to think of bipolar disease as a spectrum disorder; mild all the way to severe. Once this is diagnosed it is easy to treat. The hard part really is the diagnosis of something that can present like so many other diseases. Bipolar disorder is also highly associated with drug abuse. These patients are often medicating their mood states for relief. Ruling out a dual diagnosis is something I do for all my patients.

The treatment for Bipolar Disorder is medical, without medication you will not get better. The analogy here is like asthma; when it flares you need allergy, steroid medications and possibly an antibiotic to control the flare up. Once the acute exacerbation is under control, medication is tapered down for the majority of asthmatics; same for bipolar disease. We treat episodes and prevent as much as possible the flare ups. It's really that simple. The aim of treatment is to stabilize the mood to normal which allows normalization of thoughts (eg., racing) and behaviors (eg., slowed).

There are 3 types of medications that I use. Lithium is the gold standard and the best medication around, bar none. The problem I find with this medication is compliance and getting blood work to prevent/monitor toxicity which can be life threatening. Also long term use is associated with heart arrhythmia, kidney and thyroid disease. I rarely use this medication in my practice. The second type of medications I use are atypical anti-psychotics that are mood stabilizers but are also very helpful for manic and mixed episodes. After the mood is stable, I usually taper off these meds. The most useful class of medications that I routinely use are anti-convulsant medications, where some are better for mania, some are better for depression. I find them most useful if maintenance treatment is necessary.

Most of my patients get angry with me when I tell them I suspect Bipolar Disorder. The connotation of crazy usually comes to mind. I tell them bipolar really means just variations in the mood versus just a depressed mood. That's all that bipolar means; variation. Recognizing the variation is challenging but easy to manage and beyond what primary care doctors can do. I have found that most of my bipolar patients are quite gifted individuals. They are creative and have the ability to do things the rest of us mere mortals can't do. When their brains light up, it is a beautiful thing. My job as a psychiatrist is to keep them from flaring and flashing out. If you suffer drug abuse, chronic depression or depression that keeps coming back, see a psychiatrist. We get it.

Wonder if you have this mood disorder? Take this simple test which has recently shown to have a high degree of validity. Tell me or any psychiatrist your score. Bipolar Spectrum Diagnostic Scale

Tuesday, September 24, 2013

5 Facts About E-Cigarettes - ABC News

5 Facts About E-Cigarettes - ABC News

My patients who are trying to quit smoking frequently ask me about E-Cigarettes. Some quick facts that I think answers some questions.

Monday, June 17, 2013

Drugs and the Brain | National Institute on Drug Abuse

Drugs and the Brain | National Institute on Drug Abuse

Nice. Please, Please check this out! Just an excellent discussion on how your brain works and why addictions are diseases and not about identity, character flaw, will power etc., etc., etc. Addictions are mental illnesses that should be treated by psychiatrists. It's your brain stupid!

Sunday, June 16, 2013

Get over it!

This last month President Obama stated that we Americans need to get over the stigma of mental illness. Since then, there has been a shooting here in Santa Monica, right down the street from my office at Santa Monica College.

As a psychiatrist, I’m with the Pres on this. Life is hard but it shouldn't be that hard. If it is, there might be a mental issue that is affecting you and is easy to treat.

Often I see patients with a constellation of symptoms like poor sleep or nervousness or feeling stuck in some ground hog day mode. People think it's crazy;  no matter what they do, they are not performing at work or school or meeting realistic goals. I do very little of CRAZY. Seriously.

If your heart was skipping a beat you might notice headache, light headiness and feeling out of breath. Your doctor might tell to you to start an anti-arrhythmic drug to restore a normal heart beat. Your brain is no different. The medications I use restore normal brain functions, which are normal thoughts, emotions and behaviors. There are no artificial states. All medications work, it’s a matter of finding something that works and has no side effects for you.

Medications just alleviate symptoms. Once you can sleep, think and stop crying, I then get you involved in psychotherapy whether it’s with me or a therapist to learn better coping skills. The skills you learned 10 years ago might not be working now. So we get new skills. It’s always about the skills, not the meds.

So get real, get a grip and get WELL.

Thursday, June 6, 2013

Intervention Everyone?

Watching celebrities on T.V. being confronted by involved family and friends in staged interventions makes for great theater. Watching these people detox in front of our eyes is gratifying; they have f.+++ed up lives too. We rejoice and feel better when they at the end are clean and sober. Their redemption is our salvation, we are all well again.

The reality is only about 40,000 people in the U.S. die from drug overdose each year. This includes not only deaths from the use of legal or illegal drugs but also poisoning from medically prescribed drugs. If we subtract these accidental poisonings, the figure is lower.

In the same year, 31,000 people died from suicide, plain and simple; no exceptions. Why isn't anyone doing suicide interventions on T.V.? Why isn't anyone talking about more people dying every year from suicide than routine drug overdose? Don't get me wrong, drugs are a serious problem. Suicide from depression is a serious problem.

The symptoms of Major Depressive disorder are:
The symptoms of Major Depressive disorder are:
  • Sadness
  • Loss of interest or pleasure in usual activities
  • Changes in weight, up or down
  • Sleeping, under or over 8 hours
  • Restlessness or slowness
  • Fatigue
  • Feeling worthless, hopeless or guilty
  • Poor concentration
  • Thoughts of death or suicide
I've listed some of the symptoms above in red because most people who have no clue about anything else, can recognize these symptoms. While patients are in my waiting room, before I've even seen them, I can make the diagnosis by just noting these physical observations. Even my dog (a Chug) jumps on my bed when I'm over sleeping; she notices the changes in my behavior. If you notice these symptoms in any person you know and these symptoms have gone on for over 2 weeks, do an intervention. Get these people to their regular medical doctor ASAP. Most primary doctors can start treatment and make other arrangements that might be necessary. Yes, Major Depressive disorder is a medical illness that can be treated.

I'm sure you've recently heard to look for other symptoms of depression and suicidal intent like making a will, making a plan for suicide, etc, but come on, are you really going to ask your loved one "do you feel suicidal?" No, our own shame and horror keeps us from asking. God forbid, if they say yes. Focus on the above observable behaviors and behavioral isolation. This keeps our thoughts and conclusions out of the mix. It's not so personal but you've saved a life.

Look around you folks, think intervention. Suicide just shouldn't have to happen.

National Suicide Prevention Lifeline 1-800-273-TALK (8255)

Monday, May 27, 2013

What is Psychosomatic Medicine?

Update: Starting in 2018 Psychosomatic Medicine subspecialty is now called Consultation-Liaison Psychiatry.

Recently a doctor friend of mine asked me, "What is psychosomatic medicine?" When my answer was more vague than concrete, I realized clarification was in order.

Psychosomatic Medicine is a subspecialty of psychiatry. The American Board of Psychiatry and Neurology gives the following definition:

Subspecialization in the diagnosis and treatment of psychiatric disorders and symptoms in complex medically ill patients. This subspecialty includes treatment of patients with acute or chronic medical, neurological, obstetrical or surgical illness in which psychiatric illness is affecting their medical care and/or quality of life such as HIV infection, organ transplantation, heart disease, renal failure, cancer, stroke, traumatic brain injury, high risk pregnancy and COPD, among others. Patients also may be those who have a psychiatric disorder that is the direct consequence of a primary medical condition, or somatoform disorder or psychological factors affecting a general medical condition. Psychiatrists specializing in Psychosomatic Medicine provide consultation-liaison service in general medical hospitals, attend on medical psychiatry inpatient units, and provide collaborative care in primary care and other outpatient settings

I glazed over just trying to type this out. In a nutshell it's medical psychiatry: the interaction of the mind and body in relation to the onset, process and progression of all diseases. It's understanding and practicing a healthy mind, healthy environment and healthy personality mean physical health, mental health and well being. It is a holistic concept of disease management leading to mind and body wellness. I literally assess the psychological, neurological, endocrine and immune status of the individual. I assess the medical disease status of the individual. I understand personality, genetic and environmental factors that affect homeostasis or wellness. I evaluate and can improve patient function mentally and physically using evidence based medical treatment and psychotherapy techniques. The approach is integrative where the bio, medical, psycho and social aspects of wellness are considered. Psychosomatic medicine is the new field of integrative medicine.

As you can see the total person is evaluated; psychosomatic
medicine subspecialists leave nothing on the table.
Total health and well being is where the 3 circles intersect.

I spend most of my time with the above evaluations particularly in chronic pain management and addiction medicine. I am able to improve mental function and outcomes in the setting of medical complications such as drug withdrawal and detoxification. My treatments are aimed at achieving wellness without relapse. I minimize polypharmacy and lifelong medication use. Polypharmacy and lifelong medication is antithetical to the definition of psychosomatic medicine.

I know this definition seems long. One of my teenage patients said just call yourself an uber psychiatrist. I think I like that!

Friday, May 17, 2013

Narcotic Abuse, Dependence and Treatment

Currently in the United States, 7 million people are addicted or physically dependent to some form of opiate or prescription pain killer. Substance abuse disorders are at epidemic proportions. In my practice, I have seen many patients suffer with various addictions and/or other mental illnesses. Often these disorders are not adequately treated at rehabilitation and sober living programs where you can spend thousands of dollars to get well for 30 days; only to leave and relapse. Not only is this a waste of time and money but the experience of more failure leads to depression and anxiety aggravating more substance abuse.

A recent study, The National Center of Addiction and Substance Abuse at Colombia University, highlights the lack of care that most American’s who seek this treatment experience. It’s not enough to detox, treatment should focus on relapse prevention. Usually this should be done in the context of an outpatient office or clinic where patients not only learn to function in their environment but also thrive. Leaving a sober living in Malibu and going back home with a few skills learned over 30 days, almost always ends in relapse.

In my office as a psychiatrist, I am able to address all aspects of substance abuse including detox as well as managing other problems like anxiety, depression, mood disorders or other mental illnesses which cause people to use drugs in the first place. It is a rare person who uses and abuses narcotics in a vacuum. Most people who are suffering dependency issues are usually drug abusing in an attempt to self medicate these underlying disorders. Detoxification from all substances is usually the starting point. If there has been a history of relapse in the past, maintenance treatment is often discussed. These highly individualized treatment plans include Suboxone/buprenorphine to achieve full functioning in all aspects of your life. Usually when this goal has been attained, further sobriety and prevention of relapse can continue where medications like Vivitrol/naltrexone injectable and psychosocial support, including psychotherapy, are arranged. An essential focus of the treatment plan at this point is also treating any underlying illnesses like depression or anxiety and any debilitating symptoms like insomnia, pain, restlessness or difficulty with attention. Most rehabilitation centers or physicians who do this kind of treatment are unable to provide all these aspects of care.

Setting an appointment is easy where the initial evaluation is an hour long with weekly treatment thereafter for the first 30 days. Other collateral treatment modalities are utilized including psychotherapy, drug testing, supportive groups, meditation, yoga, or anything else that promotes your wellness. Arrangements with other health care providers and medication assistance is usually for a period of 6 months or more with continued monthly psychiatric visits. In addition to saving money, patients can get well in the quickest and easiest way possible.

If you're suffering with narcotic dependency, know that there is help that is effective and simple. You are not a drug addict. Addiction is treatable.

Sunday, January 27, 2013

Drugs, Alcohol and Blood?

I think the Twilight movies and cast of characters are kind of dumb. They are an interesting take on vampirism, being addicted to blood. I won't even get into the psycho-sexual aspects that make these movies popular but as an addiction specialist, I started to think, how would I detox a vampire from blood? Slow taper? Placebo blood type? Blood Suckers Anonymous meetings-1 less human at a time??

For my human patients, there are a lot of simple choices. Psychiatrists are best able to medically detox, stabilize and provide the psychosocial treatment and support necessary to achieve sobriety and prevent relapse. 8.9 million adults in 2009 were either chemically abusing or dependent. That's a whole lot of suffering for something that is fairly easy to treat. Below, I have listed treatments that I use, that are highly effective.

Alcohol--I use tranquilizers/benzodiazepines to detox and prevent withdrawal. Sometimes, I have to add anti-seizure medications or mood stabilizers if withdrawal is complicated. After detox, I stabilize sobriety with naltrexone pills or the new FDA approved Vivitrol injection. Generally the medication regimen is simple and short term. Campral/acamprosate during FDA trials was seen to be effective for alcohol sobriety maintenance therapy. However, the recent COMBINE study found acamprosate no better than placebo. I have found Antabuse/disulfiram helpful and do prescribe this as well.

Opiates--For office based treatment, Buprenorphine is the easiest and quickest way to sobriety and maintenance with minimal to NO withdrawal symptoms--seriously. I use this strategy for all opiate detox including methadone, which a lot of my pain patients take. Tapering off this medication, within 7-10 days or over 30 days can be easily achieved. Using other medications to prevent rebound pain, insomnia or depression is also something I can add that is different from other addiction specialists. All medications can usually wind down within 8 weeks of treatment. This new standard of less medication to achieve more health is my philosophy of mental health overall. Vivitrol injections used monthly after detox prevents relapse: yes PREVENTS. If there is a history of relapses, I maintain patients on buprenorphine to prevent further relapses. Safe, easy daily maintenance is ALWAYS better than relapsing and is EVIDENCED BASED FACT. I don't care what anybody else tells you. Tapering off when you're functional and well, is NOT the big deal everyone makes it out to be.

Stimulants--Really easy to detox from. The real problem here is the crashing mood after detox. I'm able to use mood stabilizers combined with antidepressants like Bupropion, Amoxetine and Modafinil, where patients are comfortable and functional without the white knuckles. These medications also help in preventing relapse.

Tranquilizers, Sedatives and Hypnotics--Taper strategy combined with medications to allow patients to sleep and stay comfortable during detox and to regain and maintain function.

Cigarettes--Chantix, Wellbutrin, e-cigarettes and nicotine patches or nasal spray are helpful. Cognitive Behavioral Therapy with support is the gold standard. Most of my patients have been able to stop within a few months. I often use other psychotropic medications aimed at symptom relief.

Caffeine--Yes, this is a drug I've often seen abused. If you're slamming energy drinks or coffee, wean off. Caffeine should be enjoyed like alcohol, occasionally, a few times a week. Caffeine is highly metabolic and is a major cause of anxiety that complicates detoxification of other drugs. With decaf coffee, you can get the lift without the physical effects. Placebo coffee is psychosomatic medicine at it's best and is what I do.
Now detoxing from mm. Oh I know, blood thinners! Call it aversion therapy for vampires.