Shrink Rap News

Recently, The Washington Post published an article about a spate of violent crimes involving college co-eds. In one incident, a female college student stabbed another following a dispute at an off-campus party. In another incident, a college student cut the throat of her roommate. Off campus, another high-profile crime involved a female employee of a local yoga shop who stabbed her co-worker multiple times. Are women actually committing more violent crimes lately, or are crimes committed by women just getting more media attention?

In fact, women rarely commit violent crimes. According to the Bureau of Justice Statistics, men are 10 times more likely to commit murder than women. From 2006 to 2010, per capita homicide rates overall have decreased by about 15%, and murders committed by women have followed that trend. Of the 3,000 people currently on death row, only 62 are women. Violent offenses on college campuses are also relatively rare, compared to non-campus offenses. On average, there are only about two or three campus killings per year. Thus, a campus murder committed by a co-ed is doubly unusual. These factsmay explain why murders committed by college co-eds are particularly newsworthy.

Besides the rarity of the event, violence by women is psychologically jarring. Women are stereotypically thought of as warm, nurturing, and collaborative. They are more likely to be victims of violence than perpetrators. A PubMed search using the terms “violence” and “women” yields 34,000 hits, almost all related to studies of women as victims of violence. Excluding the terms “domestic violence” and “rape” will reduce the number of studies to about 200.

Because there is relatively little known about female murderers, media portrayals of violent women tend to be far from reality. They are often portrayed as victims of circumstances beyond their control, and their crimes are mitigated by their status as victim. In the film Thelma and Louise, two women go on a cross-country crime spree after a rape. The story follows their transformation from victims to buddy-rebels. In reality, women rarely are spree killers and they usually don’t kill strangers. They tend to commit acts of violence against their children or other family members, as in the case of Andrea Yates, who killed her children during a psychotic episode. In film, even women who kill multiple victims are portrayed as being otherwise kindly, lovable, or quirky, for example, the elderly murderesses of the black comedy Arsenic and Old Lace or the suburban housewife-killer of John Waters’ Serial Mom. Aileen Wuornos, one real-life female serial killer, was a far less sympathetic character. She killed seven men in Florida and was eventually executed.

Fiction and reality may be merging, however. The HBO series “The Wire” set a new standard for fictional female psychopathy when the show featured actress Felicia Pearson as “Snoop,” a creepily callous, androgynous contract killer employed by a Baltimore drug ring. This series accurately portrayed gang-related violence and the increasing role of violent girls in these organizations.

In my experience, women also commit acts of violence for the same reasons as men: jealousy, rage, poor problem-solving skills, and substance abuse. Regardless of the cause, the response to violence and mental health interventions should not be gender-specific or exclusive. Violent women may be getting more attention lately, but violence prevention must also include attention to the mental health needs of men.

<[QM]>—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Recently, The Washington Post published an article about a spate of violent crimes involving college co-eds. In one incident, a female college student stabbed another following a dispute at an off-campus party. In another incident, a college student cut the throat of her roommate. Off campus, another high-profile crime involved a female employee of a local yoga shop who stabbed her co-worker multiple times. Are women actually committing more violent crimes lately, or are crimes committed by women just getting more media attention?

In fact, women rarely commit violent crimes. According to the Bureau of Justice Statistics, men are 10 times more likely to commit murder than women. From 2006 to 2010, per capita homicide rates overall have decreased by about 15%, and murders committed by women have followed that trend. Of the 3,000 people currently on death row, only 62 are women. Violent offenses on college campuses are also relatively rare, compared to non-campus offenses. On average, there are only about two or three campus killings per year. Thus, a campus murder committed by a co-ed is doubly unusual. These factsmay explain why murders committed by college co-eds are particularly newsworthy.

Besides the rarity of the event, violence by women is psychologically jarring. Women are stereotypically thought of as warm, nurturing, and collaborative. They are more likely to be victims of violence than perpetrators. A PubMed search using the terms “violence” and “women” yields 34,000 hits, almost all related to studies of women as victims of violence. Excluding the terms “domestic violence” and “rape” will reduce the number of studies to about 200.

Because there is relatively little known about female murderers, media portrayals of violent women tend to be far from reality. They are often portrayed as victims of circumstances beyond their control, and their crimes are mitigated by their status as victim. In the film Thelma and Louise, two women go on a cross-country crime spree after a rape. The story follows their transformation from victims to buddy-rebels. In reality, women rarely are spree killers and they usually don’t kill strangers. They tend to commit acts of violence against their children or other family members, as in the case of Andrea Yates, who killed her children during a psychotic episode. In film, even women who kill multiple victims are portrayed as being otherwise kindly, lovable, or quirky, for example, the elderly murderesses of the black comedy Arsenic and Old Lace or the suburban housewife-killer of John Waters’ Serial Mom. Aileen Wuornos, one real-life female serial killer, was a far less sympathetic character. She killed seven men in Florida and was eventually executed.

Fiction and reality may be merging, however. The HBO series “The Wire” set a new standard for fictional female psychopathy when the show featured actress Felicia Pearson as “Snoop,” a creepily callous, androgynous contract killer employed by a Baltimore drug ring. This series accurately portrayed gang-related violence and the increasing role of violent girls in these organizations.

In my experience, women also commit acts of violence for the same reasons as men: jealousy, rage, poor problem-solving skills, and substance abuse. Regardless of the cause, the response to violence and mental health interventions should not be gender-specific or exclusive. Violent women may be getting more attention lately, but violence prevention must also include attention to the mental health needs of men.

<[QM]>—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Recently, The Washington Post published an article about a spate of violent crimes involving college co-eds. In one incident, a female college student stabbed another following a dispute at an off-campus party. In another incident, a college student cut the throat of her roommate. Off campus, another high-profile crime involved a female employee of a local yoga shop who stabbed her co-worker multiple times. Are women actually committing more violent crimes lately, or are crimes committed by women just getting more media attention?

In fact, women rarely commit violent crimes. According to the Bureau of Justice Statistics, men are 10 times more likely to commit murder than women. From 2006 to 2010, per capita homicide rates overall have decreased by about 15%, and murders committed by women have followed that trend. Of the 3,000 people currently on death row, only 62 are women. Violent offenses on college campuses are also relatively rare, compared to non-campus offenses. On average, there are only about two or three campus killings per year. Thus, a campus murder committed by a co-ed is doubly unusual. These factsmay explain why murders committed by college co-eds are particularly newsworthy.

Besides the rarity of the event, violence by women is psychologically jarring. Women are stereotypically thought of as warm, nurturing, and collaborative. They are more likely to be victims of violence than perpetrators. A PubMed search using the terms “violence” and “women” yields 34,000 hits, almost all related to studies of women as victims of violence. Excluding the terms “domestic violence” and “rape” will reduce the number of studies to about 200.

Because there is relatively little known about female murderers, media portrayals of violent women tend to be far from reality. They are often portrayed as victims of circumstances beyond their control, and their crimes are mitigated by their status as victim. In the film Thelma and Louise, two women go on a cross-country crime spree after a rape. The story follows their transformation from victims to buddy-rebels. In reality, women rarely are spree killers and they usually don’t kill strangers. They tend to commit acts of violence against their children or other family members, as in the case of Andrea Yates, who killed her children during a psychotic episode. In film, even women who kill multiple victims are portrayed as being otherwise kindly, lovable, or quirky, for example, the elderly murderesses of the black comedy Arsenic and Old Lace or the suburban housewife-killer of John Waters’ Serial Mom. Aileen Wuornos, one real-life female serial killer, was a far less sympathetic character. She killed seven men in Florida and was eventually executed.

Fiction and reality may be merging, however. The HBO series “The Wire” set a new standard for fictional female psychopathy when the show featured actress Felicia Pearson as “Snoop,” a creepily callous, androgynous contract killer employed by a Baltimore drug ring. This series accurately portrayed gang-related violence and the increasing role of violent girls in these organizations.

In my experience, women also commit acts of violence for the same reasons as men: jealousy, rage, poor problem-solving skills, and substance abuse. Regardless of the cause, the response to violence and mental health interventions should not be gender-specific or exclusive. Violent women may be getting more attention lately, but violence prevention must also include attention to the mental health needs of men.

<[QM]>—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

One morning a week, I work in a community mental health center where e-prescribing has been implemented in accordance with Medicare requirements. I’m often the skeptic about such things, but I could see how e-prescribing might be useful. I assumed the first few months would be cumbersome, but then the system would be populated with information, and with a quick click, scripts would magically go to the pharmacies. Months have passed, and I’m sorry to say that e-prescribing has not gotten easier for me. The system logs me out every 7 minutes, and the number of different screens I need to click through is much less efficient than one might envision. It often take a couple of minutes of clicking, only to discover that the patient does not know the name of their pharmacy, or the pharmacy has a different name from the one they’ve given, or there are many Rite Aids on a given street and I don’t know which is “across from the Giant grocery store.” Today, I called a family member to find out the pharmacy name. In contrast, it takes me under a minute to hand-write a prescription, and e-prescribing has started to feel like a solution in search of a problem. Getting help from colleagues is difficult – the system does not have dummy data to practice with and the patient is in the room when I do this – it’s not a time when I can search for another doctor to hone my technique. Even the IT consultant needed to use her son’s antibiotic prescription to demonstrate the system. Nothing about this process has made me long for e-prescribing in my private practice.

I was going to write this article on how e-prescribing is inefficient and the Medicare penalties for not e-prescribing have come at a time when there is so much else wrong with our broken health care system that could use some fixing. Others have said the time and money required to implement e-prescribing in a private practice outweigh the 1% loss of Medicare revenues they will forfeit.

I did what I do when I want to make sure my own sense of the world of psychiatry isn’t skewed– I asked members on our Maryland Psychiatric Society listserve. My theory was that no one else likes it, either, and in fact, only a handful wrote back to say they are e-prescribing. But to my surprise, everyone who e-prescribes likes it a lot. I was the only disheartened voice. A lively discussion ensued, and other psychiatrists began talking about converting.

“I have e-prescribing as a part of my electronic health record system. It is quick, and I am very happy with it. I also feel it is the digitalized future and there is no stopping it!” wrote Dr. Patricia Sullivan, a psychiatrist in private practice in Columbia, Md.

Dr. Jeffrey Soulen, a psychiatrist in private practice in Ellicott City, Md., also wrote about his experiences over the past three years. Dr. Soulen likes seeing what other physicians are prescribing for his patients. “It’s led to some important discussions about controlled substances I didn’t know the patient was taking.” He likes the convenience of being able to access prescription information from any computer and it saves the time he used to spend calling pharmacies to add refills. “Patients love it. Once they are in the system – which takes a couple minutes the first time – it takes me no more time to send a script electronically than to hand-write it, and by the time they get to their pharmacy later that day, the script is ready for them. No need to bring a paper script and wait.”

Convenience is just one aspect of e-prescribing. The Medicare initiative to promote e-prescribing notes that medication errors are responsible for thousands of deaths every year. The hope is that computer programs will eliminate prescription errors and alert physicians to drug interactions, and will result in lower health care costs as well as decreases in patient morbidity and mortality. Has this proven to be true? It’s hard to figure that one out.

In a study by Dr. Rainu Kaushal and her colleagues in the June 2010 issue of The Journal of General Internal Medicine, the authors reported a seven-fold decrease in errors, from over 42% with written prescriptions to 6.6% a year after converting to e-prescribing. With such a remarkable change, it is worth noting that the authors used a liberal definition of “error” to include incomplete prescriptions that gave the frequency of a dose as “qd” instead of “daily” or “Take as directed.” In another article in the same journal in April, 2011, the group reported a marked increase in e-prescribing errors for first 12 weeks after e-prescribing systems are upgraded, American Medical News reports.

Dr. Kaushal, chief of the Division of Quality and Medical Informatics at Weill Cornell Medical College, said she knew that the transition from paper to electronic was difficult for most physicians. She was surprised to learn that even for experienced e-prescribers, the move to a new system can be challenging. Dr. Kaushal, who was involved in the transition studied for the report, said she found the experience to be “exceedingly difficult.” She wrote:

“We thought it would be more of a seamless transition because people were already accustomed to sitting in front of a computer, entering in orders and so on, so they didn't have to get used to that piece. But each electronic system has its nuances and learning how to utilize it and optimize the physician-computer interaction takes time. Every time a switch is made there are important issues that arise.”

In contrast, Kate L. Lapane, Ph.D., and her colleagues reported in The Journal of Pharmacy Benefits, March/April 2011, a study of 64 e-prescribing practices using six different e-prescribing software programs. In their focus groups, it was noted that prescription errors were still occurring. Prescribers cited difficulties using drop down, menus which resulted in the wrong medication or dose, and problems with small phone screens, as well as access to incomplete information and accidental duplication of prescriptions.

In another study in the Journal of the American Medical Informatics Association (June 29, 2011), Dr. Karen C. Nanji and her colleagues looked at 3,850 electronic prescriptions written over 4 weeks and found an 11.7% error rate, comparable to the error rate with handwritten prescriptions. They noted:

“Providers appear to be rapidly adopting electronic health records and computerized prescribing, and one of the major anticipated benefits is expected to be through medication-error reduction.... Many of these benefits will not be realized if the electronic prescribing applications are not mature and either do not catch or even cause new medication errors.”

I’m left to conclude that the jury is still out, both on whether e-prescribing is time-efficient and on whether it decreases the morbidity and mortality associated with medication errors.

<[QM]>—Dinah Miller, M.D.

If you’d like to read Dr. Jeffrey Soulen’s discussion of what he likes about e-prescribing, please see his guest post on our Shrink Rap blog by clicking HERE.

If you would like to comment on this article here, please register with Clinical Psychiatry News. If you are already registered, please log in to comment.

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

One morning a week, I work in a community mental health center where e-prescribing has been implemented in accordance with Medicare requirements. I’m often the skeptic about such things, but I could see how e-prescribing might be useful. I assumed the first few months would be cumbersome, but then the system would be populated with information, and with a quick click, scripts would magically go to the pharmacies. Months have passed, and I’m sorry to say that e-prescribing has not gotten easier for me. The system logs me out every 7 minutes, and the number of different screens I need to click through is much less efficient than one might envision. It often take a couple of minutes of clicking, only to discover that the patient does not know the name of their pharmacy, or the pharmacy has a different name from the one they’ve given, or there are many Rite Aids on a given street and I don’t know which is “across from the Giant grocery store.” Today, I called a family member to find out the pharmacy name. In contrast, it takes me under a minute to hand-write a prescription, and e-prescribing has started to feel like a solution in search of a problem. Getting help from colleagues is difficult – the system does not have dummy data to practice with and the patient is in the room when I do this – it’s not a time when I can search for another doctor to hone my technique. Even the IT consultant needed to use her son’s antibiotic prescription to demonstrate the system. Nothing about this process has made me long for e-prescribing in my private practice.

I was going to write this article on how e-prescribing is inefficient and the Medicare penalties for not e-prescribing have come at a time when there is so much else wrong with our broken health care system that could use some fixing. Others have said the time and money required to implement e-prescribing in a private practice outweigh the 1% loss of Medicare revenues they will forfeit.

I did what I do when I want to make sure my own sense of the world of psychiatry isn’t skewed– I asked members on our Maryland Psychiatric Society listserve. My theory was that no one else likes it, either, and in fact, only a handful wrote back to say they are e-prescribing. But to my surprise, everyone who e-prescribes likes it a lot. I was the only disheartened voice. A lively discussion ensued, and other psychiatrists began talking about converting.

“I have e-prescribing as a part of my electronic health record system. It is quick, and I am very happy with it. I also feel it is the digitalized future and there is no stopping it!” wrote Dr. Patricia Sullivan, a psychiatrist in private practice in Columbia, Md.

Dr. Jeffrey Soulen, a psychiatrist in private practice in Ellicott City, Md., also wrote about his experiences over the past three years. Dr. Soulen likes seeing what other physicians are prescribing for his patients. “It’s led to some important discussions about controlled substances I didn’t know the patient was taking.” He likes the convenience of being able to access prescription information from any computer and it saves the time he used to spend calling pharmacies to add refills. “Patients love it. Once they are in the system – which takes a couple minutes the first time – it takes me no more time to send a script electronically than to hand-write it, and by the time they get to their pharmacy later that day, the script is ready for them. No need to bring a paper script and wait.”

Convenience is just one aspect of e-prescribing. The Medicare initiative to promote e-prescribing notes that medication errors are responsible for thousands of deaths every year. The hope is that computer programs will eliminate prescription errors and alert physicians to drug interactions, and will result in lower health care costs as well as decreases in patient morbidity and mortality. Has this proven to be true? It’s hard to figure that one out.

In a study by Dr. Rainu Kaushal and her colleagues in the June 2010 issue of The Journal of General Internal Medicine, the authors reported a seven-fold decrease in errors, from over 42% with written prescriptions to 6.6% a year after converting to e-prescribing. With such a remarkable change, it is worth noting that the authors used a liberal definition of “error” to include incomplete prescriptions that gave the frequency of a dose as “qd” instead of “daily” or “Take as directed.” In another article in the same journal in April, 2011, the group reported a marked increase in e-prescribing errors for first 12 weeks after e-prescribing systems are upgraded, American Medical News reports.

Dr. Kaushal, chief of the Division of Quality and Medical Informatics at Weill Cornell Medical College, said she knew that the transition from paper to electronic was difficult for most physicians. She was surprised to learn that even for experienced e-prescribers, the move to a new system can be challenging. Dr. Kaushal, who was involved in the transition studied for the report, said she found the experience to be “exceedingly difficult.” She wrote:

“We thought it would be more of a seamless transition because people were already accustomed to sitting in front of a computer, entering in orders and so on, so they didn't have to get used to that piece. But each electronic system has its nuances and learning how to utilize it and optimize the physician-computer interaction takes time. Every time a switch is made there are important issues that arise.”

In contrast, Kate L. Lapane, Ph.D., and her colleagues reported in The Journal of Pharmacy Benefits, March/April 2011, a study of 64 e-prescribing practices using six different e-prescribing software programs. In their focus groups, it was noted that prescription errors were still occurring. Prescribers cited difficulties using drop down, menus which resulted in the wrong medication or dose, and problems with small phone screens, as well as access to incomplete information and accidental duplication of prescriptions.

In another study in the Journal of the American Medical Informatics Association (June 29, 2011), Dr. Karen C. Nanji and her colleagues looked at 3,850 electronic prescriptions written over 4 weeks and found an 11.7% error rate, comparable to the error rate with handwritten prescriptions. They noted:

“Providers appear to be rapidly adopting electronic health records and computerized prescribing, and one of the major anticipated benefits is expected to be through medication-error reduction.... Many of these benefits will not be realized if the electronic prescribing applications are not mature and either do not catch or even cause new medication errors.”

I’m left to conclude that the jury is still out, both on whether e-prescribing is time-efficient and on whether it decreases the morbidity and mortality associated with medication errors.

<[QM]>—Dinah Miller, M.D.

If you’d like to read Dr. Jeffrey Soulen’s discussion of what he likes about e-prescribing, please see his guest post on our Shrink Rap blog by clicking HERE.

If you would like to comment on this article here, please register with Clinical Psychiatry News. If you are already registered, please log in to comment.

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

One morning a week, I work in a community mental health center where e-prescribing has been implemented in accordance with Medicare requirements. I’m often the skeptic about such things, but I could see how e-prescribing might be useful. I assumed the first few months would be cumbersome, but then the system would be populated with information, and with a quick click, scripts would magically go to the pharmacies. Months have passed, and I’m sorry to say that e-prescribing has not gotten easier for me. The system logs me out every 7 minutes, and the number of different screens I need to click through is much less efficient than one might envision. It often take a couple of minutes of clicking, only to discover that the patient does not know the name of their pharmacy, or the pharmacy has a different name from the one they’ve given, or there are many Rite Aids on a given street and I don’t know which is “across from the Giant grocery store.” Today, I called a family member to find out the pharmacy name. In contrast, it takes me under a minute to hand-write a prescription, and e-prescribing has started to feel like a solution in search of a problem. Getting help from colleagues is difficult – the system does not have dummy data to practice with and the patient is in the room when I do this – it’s not a time when I can search for another doctor to hone my technique. Even the IT consultant needed to use her son’s antibiotic prescription to demonstrate the system. Nothing about this process has made me long for e-prescribing in my private practice.

I was going to write this article on how e-prescribing is inefficient and the Medicare penalties for not e-prescribing have come at a time when there is so much else wrong with our broken health care system that could use some fixing. Others have said the time and money required to implement e-prescribing in a private practice outweigh the 1% loss of Medicare revenues they will forfeit.

I did what I do when I want to make sure my own sense of the world of psychiatry isn’t skewed– I asked members on our Maryland Psychiatric Society listserve. My theory was that no one else likes it, either, and in fact, only a handful wrote back to say they are e-prescribing. But to my surprise, everyone who e-prescribes likes it a lot. I was the only disheartened voice. A lively discussion ensued, and other psychiatrists began talking about converting.

“I have e-prescribing as a part of my electronic health record system. It is quick, and I am very happy with it. I also feel it is the digitalized future and there is no stopping it!” wrote Dr. Patricia Sullivan, a psychiatrist in private practice in Columbia, Md.

Dr. Jeffrey Soulen, a psychiatrist in private practice in Ellicott City, Md., also wrote about his experiences over the past three years. Dr. Soulen likes seeing what other physicians are prescribing for his patients. “It’s led to some important discussions about controlled substances I didn’t know the patient was taking.” He likes the convenience of being able to access prescription information from any computer and it saves the time he used to spend calling pharmacies to add refills. “Patients love it. Once they are in the system – which takes a couple minutes the first time – it takes me no more time to send a script electronically than to hand-write it, and by the time they get to their pharmacy later that day, the script is ready for them. No need to bring a paper script and wait.”

Convenience is just one aspect of e-prescribing. The Medicare initiative to promote e-prescribing notes that medication errors are responsible for thousands of deaths every year. The hope is that computer programs will eliminate prescription errors and alert physicians to drug interactions, and will result in lower health care costs as well as decreases in patient morbidity and mortality. Has this proven to be true? It’s hard to figure that one out.

In a study by Dr. Rainu Kaushal and her colleagues in the June 2010 issue of The Journal of General Internal Medicine, the authors reported a seven-fold decrease in errors, from over 42% with written prescriptions to 6.6% a year after converting to e-prescribing. With such a remarkable change, it is worth noting that the authors used a liberal definition of “error” to include incomplete prescriptions that gave the frequency of a dose as “qd” instead of “daily” or “Take as directed.” In another article in the same journal in April, 2011, the group reported a marked increase in e-prescribing errors for first 12 weeks after e-prescribing systems are upgraded, American Medical News reports.

Dr. Kaushal, chief of the Division of Quality and Medical Informatics at Weill Cornell Medical College, said she knew that the transition from paper to electronic was difficult for most physicians. She was surprised to learn that even for experienced e-prescribers, the move to a new system can be challenging. Dr. Kaushal, who was involved in the transition studied for the report, said she found the experience to be “exceedingly difficult.” She wrote:

“We thought it would be more of a seamless transition because people were already accustomed to sitting in front of a computer, entering in orders and so on, so they didn't have to get used to that piece. But each electronic system has its nuances and learning how to utilize it and optimize the physician-computer interaction takes time. Every time a switch is made there are important issues that arise.”

In contrast, Kate L. Lapane, Ph.D., and her colleagues reported in The Journal of Pharmacy Benefits, March/April 2011, a study of 64 e-prescribing practices using six different e-prescribing software programs. In their focus groups, it was noted that prescription errors were still occurring. Prescribers cited difficulties using drop down, menus which resulted in the wrong medication or dose, and problems with small phone screens, as well as access to incomplete information and accidental duplication of prescriptions.

In another study in the Journal of the American Medical Informatics Association (June 29, 2011), Dr. Karen C. Nanji and her colleagues looked at 3,850 electronic prescriptions written over 4 weeks and found an 11.7% error rate, comparable to the error rate with handwritten prescriptions. They noted:

“Providers appear to be rapidly adopting electronic health records and computerized prescribing, and one of the major anticipated benefits is expected to be through medication-error reduction.... Many of these benefits will not be realized if the electronic prescribing applications are not mature and either do not catch or even cause new medication errors.”

I’m left to conclude that the jury is still out, both on whether e-prescribing is time-efficient and on whether it decreases the morbidity and mortality associated with medication errors.

<[QM]>—Dinah Miller, M.D.

If you’d like to read Dr. Jeffrey Soulen’s discussion of what he likes about e-prescribing, please see his guest post on our Shrink Rap blog by clicking HERE.

If you would like to comment on this article here, please register with Clinical Psychiatry News. If you are already registered, please log in to comment.

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

In the 1996 Academy Award-winning movie Sling Blade, actor Billy Bob Thornton played the character Karl Childers, a mentally disabled insanity acquittee hospitalized following the murder of his mother and her lover. The story followed Childers as he was abruptly released from the hospital, without warning and without preparation, to return to the community he was raised in. Although the character was portrayed sympathetically, the film nevertheless came to an unsatisfying conclusion when Childers ultimately committed another murder and returned to his bleak, unforgiving hospital ward.

As much as I enjoyed the film, I cringed at the inaccurate and horrendous portrayal of the psychiatric care given to Childers and the cavalier disregard surrounding his release. Given that John Hinckley’s release hearing has been in the news lately, I can imagine the questions raised in the mind of the general public: How can he ever be released? How can those doctors ever know that he won’t be dangerous again? Will the public be safe from him?

The decision making process for the discharge of insanity acquittees is similar to the process for voluntary psychiatric patients in non-forensic facilities and for civilly committed patients. In all cases, the decision to discharge the patient involves an assessment of the patient’s clinical status and safety issues. Doctors consider the patient’s symptoms at the time of discharge compared to admission, the patient’s level of insight, and the aftercare required following release. For non-forensic patients, an admission is often precipitated by a short-term crisis, so a release decision may involve a review of the factors leading up to admission. Since non-forensic admissions are almost always shorter than the lengths of stay for insanity acquittees, patients experience less community disruption and are more likely to have an established support system and outpatient service to return to. Unfortunately, this also means that there is less time to plan for a release or to gather potentially useful information.

Insanity acquittees face a higher barrier to community re-entry. Because lengths of stay may last several years, support systems may become disrupted or disappear entirely. The nature of the acquittee’s offense may bar him from some community services or programs, and a program may be reluctant to accept a patient with a history of violence. An acquittee’s illness may be particularly severe or treatment resistant, which would require more intensive community services or the use of limited supervised housing resources.

Fortunately, a long length of stay also allows time for release preparation. A release decision is based upon months or years of observational data to include information about the patient’s level of insight, willingness to comply with treatment, ability to self-monitor, and problem solve. The patient must be able to consider and address factors leading up to the offense. Substance abuse and personality factors often play a role, and the patient should have a demonstrated willingness to participate in therapy for this. The clinical team considers historical risk factors as well, including previous incidents of violence and the antecedents to these incidents. He must have an identified support system to rely upon in case of relapse, and often during the hospitalization the nature and quality of this support system can be reviewed by the clinical team during visits, special events, and other opportunities for interaction. If the acquittee’s victim was a family member, consideration is also given to the nature of the remaining family members’ relationships.

Although some states do not have a conditional release option, most insanity acquittees are required to follow certain requirements in order to remain in the community. Conditional release orders establish requirements very similar to parole for convicted offenders: to abstain from abuse of drugs and alcohol, to maintain a stable living situation, to comply with required treatment, and to have some type of structured daily activity. Compared to parolees, insanity acquittees typically are monitored more closely in the community, since caseloads are lower for community providers than for parole agents. Acquittees are also aware prior to release that any violation or break in conditions may lead to a quick return to the inpatient unit. Before any release can be considered, the acquittee usually also had to demonstrate a steady progression through a security level system within the facility as well as the ability to appropriately manage limited time off hospital grounds. Each change in security level involves some procedure for review or revision if indicated.

While some release processes do involve the use of formal risk assessment instruments, there is no single test that predicts successful transition to the community. And no release decision can ever be completely risk-free. Given the degree of review and planning leading to a recommendation for release, it is no surprise that insanity acquittees recidivate at a fraction of the rate of non-mentally ill parolees.

The biggest difference between the release of insanity acquittees compared to voluntary non-forensic patients is that ultimately, an insanity acquittee can only be released by a judge. Although the hospital staff and treating psychiatrist can make a recommendation about readiness for discharge, judges can disregard those recommendations. If the offense was particularly egregious or notorious, or if the case was a high-profile event with political fallout, non-clinical considerations can come into play. Some patients may demonstrate decades of symptom-free, non-violent behavior to no effect.

When a forensic patient asks his psychiatrist, “When can I go home?” the answer sometimes may be: “Never.”

<[QM—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

In the 1996 Academy Award-winning movie Sling Blade, actor Billy Bob Thornton played the character Karl Childers, a mentally disabled insanity acquittee hospitalized following the murder of his mother and her lover. The story followed Childers as he was abruptly released from the hospital, without warning and without preparation, to return to the community he was raised in. Although the character was portrayed sympathetically, the film nevertheless came to an unsatisfying conclusion when Childers ultimately committed another murder and returned to his bleak, unforgiving hospital ward.

As much as I enjoyed the film, I cringed at the inaccurate and horrendous portrayal of the psychiatric care given to Childers and the cavalier disregard surrounding his release. Given that John Hinckley’s release hearing has been in the news lately, I can imagine the questions raised in the mind of the general public: How can he ever be released? How can those doctors ever know that he won’t be dangerous again? Will the public be safe from him?

The decision making process for the discharge of insanity acquittees is similar to the process for voluntary psychiatric patients in non-forensic facilities and for civilly committed patients. In all cases, the decision to discharge the patient involves an assessment of the patient’s clinical status and safety issues. Doctors consider the patient’s symptoms at the time of discharge compared to admission, the patient’s level of insight, and the aftercare required following release. For non-forensic patients, an admission is often precipitated by a short-term crisis, so a release decision may involve a review of the factors leading up to admission. Since non-forensic admissions are almost always shorter than the lengths of stay for insanity acquittees, patients experience less community disruption and are more likely to have an established support system and outpatient service to return to. Unfortunately, this also means that there is less time to plan for a release or to gather potentially useful information.

Insanity acquittees face a higher barrier to community re-entry. Because lengths of stay may last several years, support systems may become disrupted or disappear entirely. The nature of the acquittee’s offense may bar him from some community services or programs, and a program may be reluctant to accept a patient with a history of violence. An acquittee’s illness may be particularly severe or treatment resistant, which would require more intensive community services or the use of limited supervised housing resources.

Fortunately, a long length of stay also allows time for release preparation. A release decision is based upon months or years of observational data to include information about the patient’s level of insight, willingness to comply with treatment, ability to self-monitor, and problem solve. The patient must be able to consider and address factors leading up to the offense. Substance abuse and personality factors often play a role, and the patient should have a demonstrated willingness to participate in therapy for this. The clinical team considers historical risk factors as well, including previous incidents of violence and the antecedents to these incidents. He must have an identified support system to rely upon in case of relapse, and often during the hospitalization the nature and quality of this support system can be reviewed by the clinical team during visits, special events, and other opportunities for interaction. If the acquittee’s victim was a family member, consideration is also given to the nature of the remaining family members’ relationships.

Although some states do not have a conditional release option, most insanity acquittees are required to follow certain requirements in order to remain in the community. Conditional release orders establish requirements very similar to parole for convicted offenders: to abstain from abuse of drugs and alcohol, to maintain a stable living situation, to comply with required treatment, and to have some type of structured daily activity. Compared to parolees, insanity acquittees typically are monitored more closely in the community, since caseloads are lower for community providers than for parole agents. Acquittees are also aware prior to release that any violation or break in conditions may lead to a quick return to the inpatient unit. Before any release can be considered, the acquittee usually also had to demonstrate a steady progression through a security level system within the facility as well as the ability to appropriately manage limited time off hospital grounds. Each change in security level involves some procedure for review or revision if indicated.

While some release processes do involve the use of formal risk assessment instruments, there is no single test that predicts successful transition to the community. And no release decision can ever be completely risk-free. Given the degree of review and planning leading to a recommendation for release, it is no surprise that insanity acquittees recidivate at a fraction of the rate of non-mentally ill parolees.

The biggest difference between the release of insanity acquittees compared to voluntary non-forensic patients is that ultimately, an insanity acquittee can only be released by a judge. Although the hospital staff and treating psychiatrist can make a recommendation about readiness for discharge, judges can disregard those recommendations. If the offense was particularly egregious or notorious, or if the case was a high-profile event with political fallout, non-clinical considerations can come into play. Some patients may demonstrate decades of symptom-free, non-violent behavior to no effect.

When a forensic patient asks his psychiatrist, “When can I go home?” the answer sometimes may be: “Never.”

<[QM—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

In the 1996 Academy Award-winning movie Sling Blade, actor Billy Bob Thornton played the character Karl Childers, a mentally disabled insanity acquittee hospitalized following the murder of his mother and her lover. The story followed Childers as he was abruptly released from the hospital, without warning and without preparation, to return to the community he was raised in. Although the character was portrayed sympathetically, the film nevertheless came to an unsatisfying conclusion when Childers ultimately committed another murder and returned to his bleak, unforgiving hospital ward.

As much as I enjoyed the film, I cringed at the inaccurate and horrendous portrayal of the psychiatric care given to Childers and the cavalier disregard surrounding his release. Given that John Hinckley’s release hearing has been in the news lately, I can imagine the questions raised in the mind of the general public: How can he ever be released? How can those doctors ever know that he won’t be dangerous again? Will the public be safe from him?

The decision making process for the discharge of insanity acquittees is similar to the process for voluntary psychiatric patients in non-forensic facilities and for civilly committed patients. In all cases, the decision to discharge the patient involves an assessment of the patient’s clinical status and safety issues. Doctors consider the patient’s symptoms at the time of discharge compared to admission, the patient’s level of insight, and the aftercare required following release. For non-forensic patients, an admission is often precipitated by a short-term crisis, so a release decision may involve a review of the factors leading up to admission. Since non-forensic admissions are almost always shorter than the lengths of stay for insanity acquittees, patients experience less community disruption and are more likely to have an established support system and outpatient service to return to. Unfortunately, this also means that there is less time to plan for a release or to gather potentially useful information.

Insanity acquittees face a higher barrier to community re-entry. Because lengths of stay may last several years, support systems may become disrupted or disappear entirely. The nature of the acquittee’s offense may bar him from some community services or programs, and a program may be reluctant to accept a patient with a history of violence. An acquittee’s illness may be particularly severe or treatment resistant, which would require more intensive community services or the use of limited supervised housing resources.

Fortunately, a long length of stay also allows time for release preparation. A release decision is based upon months or years of observational data to include information about the patient’s level of insight, willingness to comply with treatment, ability to self-monitor, and problem solve. The patient must be able to consider and address factors leading up to the offense. Substance abuse and personality factors often play a role, and the patient should have a demonstrated willingness to participate in therapy for this. The clinical team considers historical risk factors as well, including previous incidents of violence and the antecedents to these incidents. He must have an identified support system to rely upon in case of relapse, and often during the hospitalization the nature and quality of this support system can be reviewed by the clinical team during visits, special events, and other opportunities for interaction. If the acquittee’s victim was a family member, consideration is also given to the nature of the remaining family members’ relationships.

Although some states do not have a conditional release option, most insanity acquittees are required to follow certain requirements in order to remain in the community. Conditional release orders establish requirements very similar to parole for convicted offenders: to abstain from abuse of drugs and alcohol, to maintain a stable living situation, to comply with required treatment, and to have some type of structured daily activity. Compared to parolees, insanity acquittees typically are monitored more closely in the community, since caseloads are lower for community providers than for parole agents. Acquittees are also aware prior to release that any violation or break in conditions may lead to a quick return to the inpatient unit. Before any release can be considered, the acquittee usually also had to demonstrate a steady progression through a security level system within the facility as well as the ability to appropriately manage limited time off hospital grounds. Each change in security level involves some procedure for review or revision if indicated.

While some release processes do involve the use of formal risk assessment instruments, there is no single test that predicts successful transition to the community. And no release decision can ever be completely risk-free. Given the degree of review and planning leading to a recommendation for release, it is no surprise that insanity acquittees recidivate at a fraction of the rate of non-mentally ill parolees.

The biggest difference between the release of insanity acquittees compared to voluntary non-forensic patients is that ultimately, an insanity acquittee can only be released by a judge. Although the hospital staff and treating psychiatrist can make a recommendation about readiness for discharge, judges can disregard those recommendations. If the offense was particularly egregious or notorious, or if the case was a high-profile event with political fallout, non-clinical considerations can come into play. Some patients may demonstrate decades of symptom-free, non-violent behavior to no effect.

When a forensic patient asks his psychiatrist, “When can I go home?” the answer sometimes may be: “Never.”

<[QM—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

At the American Psychiatric Association’s November Assembly meeting, Dr. Judith Kashtan (with co-author Dr. Ramaswamy Viswanathan) put forth an action paper aimed at encouraging the APA to do more to educate and assist its members in making decisions about implementing electronic health records (EHRs). The proposal was debated in its assigned Reference Committee, which made revisions to the action paper before sending it back to the floor of the Assembly for discussion, further revision, and voting.

The final paper, “Improved EHR Education for Members in Solo Private Practice,” was overwhelmingly approved by the APA Assembly. This is a very timely and relevant topic, as the Centers for Medicare and Medicaid Services (CMS) is providing a small bonus for physicians who employ an EHR in their practice, and a small fee reduction for those of us who do not. This is giving many physicians a lot of anxiety over how to change their practice.

I’ll come back to this in a minute, but first I will explain the big picture of how the Assembly works for those readers who don’t know much about it. The Assembly is the deliberative body of the APA, very much like the U.S. House of Representatives. Each district branch votes on a number of Assembly representatives (and deputy representatives) proportional to the size of the APA membership in that branch. A smaller number of “reps” represent certain defined groups of members. An Assembly rep can propose an item for the Assembly to vote on.

Such items, called Action Papers, get vetted at the local level before coming to the Assembly. (There are actually more steps, but that is more detail than necessary here.) An Action Paper starts out with numerous “Whereas” statements that explain the background and reason for the paper, followed by several “Be It Resolved” statements that advise the APA what the Assembly wants the organization to do. This is how position statements get crafted, as well as how other policies and member needs get communicated to the Board of Trustees, which has the ultimate decision-making responsibility for the organization.

The Assembly meets twice per year, in November and in May. The Action Papers get divided up into Reference Committees, somewhat analogous to the various House of Representatives committees. Each committee, which may have about 8-10 people on it, hears from the paper’s author about why the paper has merit, while other reps and APA members may speak for or against the paper. At this time, further revisions or amendments may get made to the paper. The Reference Committee then makes a decision to support the paper or not, communicating that decision along with any revisions to the Assembly.

The Assembly then discusses each paper and votes to approve it or not. While I missed the Assembly discussion for this EHR Action Paper, I was present for the Reference Committee discussion where I spoke as the chair of the Committee on EHRs. The concerns raised had to do with this coming freight train of having to select an EHR, how to go about making such a decision, how to implement it and convert from paper to electronic, and what are the costs involved. The Action Paper requests the EHR committee to supplement the materials on its website, in addition to providing an area for members to discuss and compare their experiences with their own EHR, while providing additional staff support to make this happen.

The APA currently has a section on its website devoted to EHRs. This section contains important links describing the CMS incentive program, explaining the national EHR initiatives, and addressing related privacy, security, and technical issues. There is also a members-only section where one can read member reviews of several EHRs, though presently we have only 15 reviews on the site. The committee has been working for the past several months on developing an improved method that would help members provide reviews of what they have used, while also providing a framework that helps them think through the relevant issues when deciding on an EHR.

The most important decision to make is whether you want to have an EHR or continue to use your current method of documenting care. Most of us will not need to weigh the financial carrots and sticks from CMS, since they are only relevant if you have a sizable Medicaid or Medicare population. The stick amounts to up to 3% of your Medicare fees. Given that a 27% cut in Medicare fees is now on the table (or 39% per MedPAC), 3% is not worth getting excited over. Rather, the cost of the system itself will be the main financial consideration.

Other considerations have more to do with the sort of practice one has and the need for sharing information. Thinking through the risks and benefits of adopting an EHR in one’s practice can help reduce the angst one feels about this decision:

POTENTIAL BENEFITS:

• quicker exchange of information than with faxing or mailing

• less likely for papers to get misfiled or lost (eg, think Hurricane Katrina)

• better tracking of who accessed what information

• less duplication of tests

• improved coordination of care

• fewer medical errors due to more information available

• decreased liability due to sharing of important information with other providers

• improved legibility

POTENTIAL RISKS:

• decreased privacy due to potential for data breach, identity theft

• loss of data due to technical problems (viruses, hardware failure, etc)

• failure to secure data due to inadequate authentication, authorization, encryption, etc

• more errors in health record due to automated data collection processes

• increased liability due to sharing of sensitive information with other providers

Finally, just because it is electronic doesn’t necessarily make it better or safer. The Institute of Medicine recently recommended that a separate entity investigate errors resulting from the use of electronic health records, while a report in this month’s Journal of the American Medical Informatics Association found that 10% of electronic prescriptions to a commercial outpatient pharmacy chain had errors, one-third of them potentially serious. This is similar to the error rate in handwritten prescriptions.

The APA Committee on Electronic Health Records will be coming out next spring with an improved tool to assist its members in sharing their experiences with the numerous EHR products out there. Until then, ask your colleagues, go online, and share with others. Also stay tuned here, and on my blog, HIT Shrink.

<[QM]>—Steven Roy Daviss, M.D. DFAPA

Dr. Daviss is chair of the department of psychiatry at Baltimore Washington Medical Center, clinical assistant professor at University of Maryland, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. Find him @HITshrink on Twitter and on the Shrink Rap blog.

At the American Psychiatric Association’s November Assembly meeting, Dr. Judith Kashtan (with co-author Dr. Ramaswamy Viswanathan) put forth an action paper aimed at encouraging the APA to do more to educate and assist its members in making decisions about implementing electronic health records (EHRs). The proposal was debated in its assigned Reference Committee, which made revisions to the action paper before sending it back to the floor of the Assembly for discussion, further revision, and voting.

The final paper, “Improved EHR Education for Members in Solo Private Practice,” was overwhelmingly approved by the APA Assembly. This is a very timely and relevant topic, as the Centers for Medicare and Medicaid Services (CMS) is providing a small bonus for physicians who employ an EHR in their practice, and a small fee reduction for those of us who do not. This is giving many physicians a lot of anxiety over how to change their practice.

I’ll come back to this in a minute, but first I will explain the big picture of how the Assembly works for those readers who don’t know much about it. The Assembly is the deliberative body of the APA, very much like the U.S. House of Representatives. Each district branch votes on a number of Assembly representatives (and deputy representatives) proportional to the size of the APA membership in that branch. A smaller number of “reps” represent certain defined groups of members. An Assembly rep can propose an item for the Assembly to vote on.

Such items, called Action Papers, get vetted at the local level before coming to the Assembly. (There are actually more steps, but that is more detail than necessary here.) An Action Paper starts out with numerous “Whereas” statements that explain the background and reason for the paper, followed by several “Be It Resolved” statements that advise the APA what the Assembly wants the organization to do. This is how position statements get crafted, as well as how other policies and member needs get communicated to the Board of Trustees, which has the ultimate decision-making responsibility for the organization.

The Assembly meets twice per year, in November and in May. The Action Papers get divided up into Reference Committees, somewhat analogous to the various House of Representatives committees. Each committee, which may have about 8-10 people on it, hears from the paper’s author about why the paper has merit, while other reps and APA members may speak for or against the paper. At this time, further revisions or amendments may get made to the paper. The Reference Committee then makes a decision to support the paper or not, communicating that decision along with any revisions to the Assembly.

The Assembly then discusses each paper and votes to approve it or not. While I missed the Assembly discussion for this EHR Action Paper, I was present for the Reference Committee discussion where I spoke as the chair of the Committee on EHRs. The concerns raised had to do with this coming freight train of having to select an EHR, how to go about making such a decision, how to implement it and convert from paper to electronic, and what are the costs involved. The Action Paper requests the EHR committee to supplement the materials on its website, in addition to providing an area for members to discuss and compare their experiences with their own EHR, while providing additional staff support to make this happen.

The APA currently has a section on its website devoted to EHRs. This section contains important links describing the CMS incentive program, explaining the national EHR initiatives, and addressing related privacy, security, and technical issues. There is also a members-only section where one can read member reviews of several EHRs, though presently we have only 15 reviews on the site. The committee has been working for the past several months on developing an improved method that would help members provide reviews of what they have used, while also providing a framework that helps them think through the relevant issues when deciding on an EHR.

The most important decision to make is whether you want to have an EHR or continue to use your current method of documenting care. Most of us will not need to weigh the financial carrots and sticks from CMS, since they are only relevant if you have a sizable Medicaid or Medicare population. The stick amounts to up to 3% of your Medicare fees. Given that a 27% cut in Medicare fees is now on the table (or 39% per MedPAC), 3% is not worth getting excited over. Rather, the cost of the system itself will be the main financial consideration.

Other considerations have more to do with the sort of practice one has and the need for sharing information. Thinking through the risks and benefits of adopting an EHR in one’s practice can help reduce the angst one feels about this decision:

POTENTIAL BENEFITS:

• quicker exchange of information than with faxing or mailing

• less likely for papers to get misfiled or lost (eg, think Hurricane Katrina)

• better tracking of who accessed what information

• less duplication of tests

• improved coordination of care

• fewer medical errors due to more information available

• decreased liability due to sharing of important information with other providers

• improved legibility

POTENTIAL RISKS:

• decreased privacy due to potential for data breach, identity theft

• loss of data due to technical problems (viruses, hardware failure, etc)

• failure to secure data due to inadequate authentication, authorization, encryption, etc

• more errors in health record due to automated data collection processes

• increased liability due to sharing of sensitive information with other providers

Finally, just because it is electronic doesn’t necessarily make it better or safer. The Institute of Medicine recently recommended that a separate entity investigate errors resulting from the use of electronic health records, while a report in this month’s Journal of the American Medical Informatics Association found that 10% of electronic prescriptions to a commercial outpatient pharmacy chain had errors, one-third of them potentially serious. This is similar to the error rate in handwritten prescriptions.

The APA Committee on Electronic Health Records will be coming out next spring with an improved tool to assist its members in sharing their experiences with the numerous EHR products out there. Until then, ask your colleagues, go online, and share with others. Also stay tuned here, and on my blog, HIT Shrink.

<[QM]>—Steven Roy Daviss, M.D. DFAPA

Dr. Daviss is chair of the department of psychiatry at Baltimore Washington Medical Center, clinical assistant professor at University of Maryland, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. Find him @HITshrink on Twitter and on the Shrink Rap blog.

At the American Psychiatric Association’s November Assembly meeting, Dr. Judith Kashtan (with co-author Dr. Ramaswamy Viswanathan) put forth an action paper aimed at encouraging the APA to do more to educate and assist its members in making decisions about implementing electronic health records (EHRs). The proposal was debated in its assigned Reference Committee, which made revisions to the action paper before sending it back to the floor of the Assembly for discussion, further revision, and voting.

The final paper, “Improved EHR Education for Members in Solo Private Practice,” was overwhelmingly approved by the APA Assembly. This is a very timely and relevant topic, as the Centers for Medicare and Medicaid Services (CMS) is providing a small bonus for physicians who employ an EHR in their practice, and a small fee reduction for those of us who do not. This is giving many physicians a lot of anxiety over how to change their practice.

I’ll come back to this in a minute, but first I will explain the big picture of how the Assembly works for those readers who don’t know much about it. The Assembly is the deliberative body of the APA, very much like the U.S. House of Representatives. Each district branch votes on a number of Assembly representatives (and deputy representatives) proportional to the size of the APA membership in that branch. A smaller number of “reps” represent certain defined groups of members. An Assembly rep can propose an item for the Assembly to vote on.

Such items, called Action Papers, get vetted at the local level before coming to the Assembly. (There are actually more steps, but that is more detail than necessary here.) An Action Paper starts out with numerous “Whereas” statements that explain the background and reason for the paper, followed by several “Be It Resolved” statements that advise the APA what the Assembly wants the organization to do. This is how position statements get crafted, as well as how other policies and member needs get communicated to the Board of Trustees, which has the ultimate decision-making responsibility for the organization.

The Assembly meets twice per year, in November and in May. The Action Papers get divided up into Reference Committees, somewhat analogous to the various House of Representatives committees. Each committee, which may have about 8-10 people on it, hears from the paper’s author about why the paper has merit, while other reps and APA members may speak for or against the paper. At this time, further revisions or amendments may get made to the paper. The Reference Committee then makes a decision to support the paper or not, communicating that decision along with any revisions to the Assembly.

The Assembly then discusses each paper and votes to approve it or not. While I missed the Assembly discussion for this EHR Action Paper, I was present for the Reference Committee discussion where I spoke as the chair of the Committee on EHRs. The concerns raised had to do with this coming freight train of having to select an EHR, how to go about making such a decision, how to implement it and convert from paper to electronic, and what are the costs involved. The Action Paper requests the EHR committee to supplement the materials on its website, in addition to providing an area for members to discuss and compare their experiences with their own EHR, while providing additional staff support to make this happen.

The APA currently has a section on its website devoted to EHRs. This section contains important links describing the CMS incentive program, explaining the national EHR initiatives, and addressing related privacy, security, and technical issues. There is also a members-only section where one can read member reviews of several EHRs, though presently we have only 15 reviews on the site. The committee has been working for the past several months on developing an improved method that would help members provide reviews of what they have used, while also providing a framework that helps them think through the relevant issues when deciding on an EHR.

The most important decision to make is whether you want to have an EHR or continue to use your current method of documenting care. Most of us will not need to weigh the financial carrots and sticks from CMS, since they are only relevant if you have a sizable Medicaid or Medicare population. The stick amounts to up to 3% of your Medicare fees. Given that a 27% cut in Medicare fees is now on the table (or 39% per MedPAC), 3% is not worth getting excited over. Rather, the cost of the system itself will be the main financial consideration.

Other considerations have more to do with the sort of practice one has and the need for sharing information. Thinking through the risks and benefits of adopting an EHR in one’s practice can help reduce the angst one feels about this decision:

POTENTIAL BENEFITS:

• quicker exchange of information than with faxing or mailing

• less likely for papers to get misfiled or lost (eg, think Hurricane Katrina)

• better tracking of who accessed what information

• less duplication of tests

• improved coordination of care

• fewer medical errors due to more information available

• decreased liability due to sharing of important information with other providers

• improved legibility

POTENTIAL RISKS:

• decreased privacy due to potential for data breach, identity theft

• loss of data due to technical problems (viruses, hardware failure, etc)

• failure to secure data due to inadequate authentication, authorization, encryption, etc

• more errors in health record due to automated data collection processes

• increased liability due to sharing of sensitive information with other providers

Finally, just because it is electronic doesn’t necessarily make it better or safer. The Institute of Medicine recently recommended that a separate entity investigate errors resulting from the use of electronic health records, while a report in this month’s Journal of the American Medical Informatics Association found that 10% of electronic prescriptions to a commercial outpatient pharmacy chain had errors, one-third of them potentially serious. This is similar to the error rate in handwritten prescriptions.

The APA Committee on Electronic Health Records will be coming out next spring with an improved tool to assist its members in sharing their experiences with the numerous EHR products out there. Until then, ask your colleagues, go online, and share with others. Also stay tuned here, and on my blog, HIT Shrink.

<[QM]>—Steven Roy Daviss, M.D. DFAPA

Dr. Daviss is chair of the department of psychiatry at Baltimore Washington Medical Center, clinical assistant professor at University of Maryland, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. Find him @HITshrink on Twitter and on the Shrink Rap blog.

Those readers who follow our Shrink Rap blog know that I have a conflicted relationship with technology. My fascination with the many forms of connectedness that flow on the Internet is time-consuming and I only recently surrendered to a smart phone. I waited for the delivery of my new iPhone 4s and I started to wonder if the Siri function – advertised as a “personal assistant” – could make my life as a solo practitioner with no employees any easier. For the weeks before its arrival, I constantly wondered, “Will Siri be able to do this?” The anticipation built and I knew I was setting myself up for disappointment.

It’s been a couple of weeks now, and even after purchasing a How to Use Siri book (which I read on the phone), I still don’t have the complete hang of it. When it works well, it feels very efficient and almost like a miracle has transpired. When it doesn’t work, I wonder if it’s my fault or Siri’s and I struggle to get it right. Unfortunately, communication with Siri is a spoken event, and everyone else in the room gets to listen as I issue the same instructions over and over. So far, I have not used Siri in the presence of patients. Showing off Siri is a little like trying to parade a toddler’s ability to perform cute tasks – sometimes the child (or Siri) will perform for others, but often times she won’t.

Missed appointments create an inconvenience in the life of a private practitioner, and I will sometimes text patients to remind them of their appointments. With Siri, this is a very fast process. I hold up the phone and say “Please send a text to John Jones: Appointment reminder for tomorrow at 3.” It takes seconds and Siri is very good at locating the right person from my contact list.

In general, texting or dictating e-mails are much faster, but Siri’s accuracy seems to depend on a number of things. The dictation works best if there is no background noise. Speaking slowly and articulating each word improves – but does not perfect – the accuracy. Once the message is dictated, touching the screen allows the user to correct mistakes with key strokes. Overall, however, the accuracy of Siri’s ability to understand is disappointing and sometimes requires multiple attempts. As an example, I said to Siri, “Please e-mail Anne Hanson” (one of my co-authors). Siri did not quite understand the name. It responded, “Okay, who shall I e-mail?” and set up an e-mail with the subject line “in” (which I assume was a misinterpretation of “Anne.”) I repeated, “Anne Hanson,” a name Siri knows well. The response I received was rather perplexing, it said, “My mind is going, Dinah. It really is going.” Oh my, as a psychiatrist the last thing I need is emotionally unbalanced machinery.

Siri will add or delete calendar events and will warn of conflicts, or search for specific events. It will find contacts, but not add new ones or edit existing information. It will answer some questions, and is much faster and more accurate at serial calculations then I am with a touch screen calculator. It will answer specific questions (“What’s the weather?” “How old is Woody Allen?” “Where can I buy a hot dog?”) It will text, e-mail, create reminders, make a note, schedule (with issues), find a contact and map the way to that contact’s location, calculate, suggest restaurants, and search the web. It sets alarms more quickly and efficiently then any alarm clock with a simple, “Wake me at 7.” It will read texts aloud, but not e-mails. Sometimes it speaks and sometimes it shows. It is fairly quick to say: “I can’t help you with that.” It will play a specific song or playlist from the iPhone’s library. I asked Siri, “At 8:05, ‘play Horse With No Name.” Siri ignored the time request and began playing the song, I asked it to stop, and it replied, “Ok, I will play Stop! In The Name of Love,” and it did.

Siri does not interface with other Apps, and so it can’t be used with my billing software, medical apps, to post to Facebook or Twitter, and sadly, it absolutely insists that Shrink Rap is spelled Shrink Wrap, something I have unable to correct. At times, the system has gone down and Siri has been unable to connect with the network, but I suppose even human personal assistants call in sick.

What about for actual psychiatric uses, how does Siri fare? I asked Siri for a referral to a psychiatrist and it gave 15 listings, “fairly close to you.” One was a psychologist (Siri!), several were the names of hospitals, and for unclear reasons, the Maryland State Government Academic Services was among the listings. I was not among the psychiatrists listed, and I was certainly the closest to me at the time I asked. If the user wants to jump off a bridge, Siri gives a list of bridges in the vicinity – probably not what the patient’s psychiatrist might hope for.

Others are using Siri to answer more existential questions. Dr. Robert Roca, vice president of medical affairs at Sheppard Pratt Hospital has found Siri to be helpful in finding the meaning of life. “When I asked, she made some comment about a play where nothing happens,” Dr. Roca wrote. And when I asked Siri the meaning of life, it replied, “All evidence to date suggests chocolate,” leading me to wonder if Siri knows something about my psyche as compared to Dr. Roca’s.

Dr. Paul Nestadt, a psychiatry resident at Johns Hopkins Hospital, states: “Siri’s psychiatric training is somewhat lacking, although she does have a very analytical philosophy when it comes to psychotherapy. A patient can talk to her for hours without her making any interpretations. I did find myself experiencing some transference with her, demanding things from her with the same impatience I had with my mother as a small child.”

A personal assistant? Not quite. The comprehension/dictation system needs to be much better, as does the interface with other iPhone apps. Oh, but it is a lot of fun. Siri, please submit this article.

<[QM]>—Dinah Miller, M.D.

If you are a health professional and would like to comment on this article, please register with Clinical Psychiatry News. If you are already registered, please log in to comment. You are also welcome to join the discussion on Shrink Rap -- go to the November 16, 2011 post titled “Technology and the Shrink.”

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

Those readers who follow our Shrink Rap blog know that I have a conflicted relationship with technology. My fascination with the many forms of connectedness that flow on the Internet is time-consuming and I only recently surrendered to a smart phone. I waited for the delivery of my new iPhone 4s and I started to wonder if the Siri function – advertised as a “personal assistant” – could make my life as a solo practitioner with no employees any easier. For the weeks before its arrival, I constantly wondered, “Will Siri be able to do this?” The anticipation built and I knew I was setting myself up for disappointment.

It’s been a couple of weeks now, and even after purchasing a How to Use Siri book (which I read on the phone), I still don’t have the complete hang of it. When it works well, it feels very efficient and almost like a miracle has transpired. When it doesn’t work, I wonder if it’s my fault or Siri’s and I struggle to get it right. Unfortunately, communication with Siri is a spoken event, and everyone else in the room gets to listen as I issue the same instructions over and over. So far, I have not used Siri in the presence of patients. Showing off Siri is a little like trying to parade a toddler’s ability to perform cute tasks – sometimes the child (or Siri) will perform for others, but often times she won’t.

Missed appointments create an inconvenience in the life of a private practitioner, and I will sometimes text patients to remind them of their appointments. With Siri, this is a very fast process. I hold up the phone and say “Please send a text to John Jones: Appointment reminder for tomorrow at 3.” It takes seconds and Siri is very good at locating the right person from my contact list.

In general, texting or dictating e-mails are much faster, but Siri’s accuracy seems to depend on a number of things. The dictation works best if there is no background noise. Speaking slowly and articulating each word improves – but does not perfect – the accuracy. Once the message is dictated, touching the screen allows the user to correct mistakes with key strokes. Overall, however, the accuracy of Siri’s ability to understand is disappointing and sometimes requires multiple attempts. As an example, I said to Siri, “Please e-mail Anne Hanson” (one of my co-authors). Siri did not quite understand the name. It responded, “Okay, who shall I e-mail?” and set up an e-mail with the subject line “in” (which I assume was a misinterpretation of “Anne.”) I repeated, “Anne Hanson,” a name Siri knows well. The response I received was rather perplexing, it said, “My mind is going, Dinah. It really is going.” Oh my, as a psychiatrist the last thing I need is emotionally unbalanced machinery.

Siri will add or delete calendar events and will warn of conflicts, or search for specific events. It will find contacts, but not add new ones or edit existing information. It will answer some questions, and is much faster and more accurate at serial calculations then I am with a touch screen calculator. It will answer specific questions (“What’s the weather?” “How old is Woody Allen?” “Where can I buy a hot dog?”) It will text, e-mail, create reminders, make a note, schedule (with issues), find a contact and map the way to that contact’s location, calculate, suggest restaurants, and search the web. It sets alarms more quickly and efficiently then any alarm clock with a simple, “Wake me at 7.” It will read texts aloud, but not e-mails. Sometimes it speaks and sometimes it shows. It is fairly quick to say: “I can’t help you with that.” It will play a specific song or playlist from the iPhone’s library. I asked Siri, “At 8:05, ‘play Horse With No Name.” Siri ignored the time request and began playing the song, I asked it to stop, and it replied, “Ok, I will play Stop! In The Name of Love,” and it did.

Siri does not interface with other Apps, and so it can’t be used with my billing software, medical apps, to post to Facebook or Twitter, and sadly, it absolutely insists that Shrink Rap is spelled Shrink Wrap, something I have unable to correct. At times, the system has gone down and Siri has been unable to connect with the network, but I suppose even human personal assistants call in sick.

What about for actual psychiatric uses, how does Siri fare? I asked Siri for a referral to a psychiatrist and it gave 15 listings, “fairly close to you.” One was a psychologist (Siri!), several were the names of hospitals, and for unclear reasons, the Maryland State Government Academic Services was among the listings. I was not among the psychiatrists listed, and I was certainly the closest to me at the time I asked. If the user wants to jump off a bridge, Siri gives a list of bridges in the vicinity – probably not what the patient’s psychiatrist might hope for.

Others are using Siri to answer more existential questions. Dr. Robert Roca, vice president of medical affairs at Sheppard Pratt Hospital has found Siri to be helpful in finding the meaning of life. “When I asked, she made some comment about a play where nothing happens,” Dr. Roca wrote. And when I asked Siri the meaning of life, it replied, “All evidence to date suggests chocolate,” leading me to wonder if Siri knows something about my psyche as compared to Dr. Roca’s.

Dr. Paul Nestadt, a psychiatry resident at Johns Hopkins Hospital, states: “Siri’s psychiatric training is somewhat lacking, although she does have a very analytical philosophy when it comes to psychotherapy. A patient can talk to her for hours without her making any interpretations. I did find myself experiencing some transference with her, demanding things from her with the same impatience I had with my mother as a small child.”

A personal assistant? Not quite. The comprehension/dictation system needs to be much better, as does the interface with other iPhone apps. Oh, but it is a lot of fun. Siri, please submit this article.

<[QM]>—Dinah Miller, M.D.

If you are a health professional and would like to comment on this article, please register with Clinical Psychiatry News. If you are already registered, please log in to comment. You are also welcome to join the discussion on Shrink Rap -- go to the November 16, 2011 post titled “Technology and the Shrink.”

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

Those readers who follow our Shrink Rap blog know that I have a conflicted relationship with technology. My fascination with the many forms of connectedness that flow on the Internet is time-consuming and I only recently surrendered to a smart phone. I waited for the delivery of my new iPhone 4s and I started to wonder if the Siri function – advertised as a “personal assistant” – could make my life as a solo practitioner with no employees any easier. For the weeks before its arrival, I constantly wondered, “Will Siri be able to do this?” The anticipation built and I knew I was setting myself up for disappointment.

It’s been a couple of weeks now, and even after purchasing a How to Use Siri book (which I read on the phone), I still don’t have the complete hang of it. When it works well, it feels very efficient and almost like a miracle has transpired. When it doesn’t work, I wonder if it’s my fault or Siri’s and I struggle to get it right. Unfortunately, communication with Siri is a spoken event, and everyone else in the room gets to listen as I issue the same instructions over and over. So far, I have not used Siri in the presence of patients. Showing off Siri is a little like trying to parade a toddler’s ability to perform cute tasks – sometimes the child (or Siri) will perform for others, but often times she won’t.

Missed appointments create an inconvenience in the life of a private practitioner, and I will sometimes text patients to remind them of their appointments. With Siri, this is a very fast process. I hold up the phone and say “Please send a text to John Jones: Appointment reminder for tomorrow at 3.” It takes seconds and Siri is very good at locating the right person from my contact list.

In general, texting or dictating e-mails are much faster, but Siri’s accuracy seems to depend on a number of things. The dictation works best if there is no background noise. Speaking slowly and articulating each word improves – but does not perfect – the accuracy. Once the message is dictated, touching the screen allows the user to correct mistakes with key strokes. Overall, however, the accuracy of Siri’s ability to understand is disappointing and sometimes requires multiple attempts. As an example, I said to Siri, “Please e-mail Anne Hanson” (one of my co-authors). Siri did not quite understand the name. It responded, “Okay, who shall I e-mail?” and set up an e-mail with the subject line “in” (which I assume was a misinterpretation of “Anne.”) I repeated, “Anne Hanson,” a name Siri knows well. The response I received was rather perplexing, it said, “My mind is going, Dinah. It really is going.” Oh my, as a psychiatrist the last thing I need is emotionally unbalanced machinery.

Siri will add or delete calendar events and will warn of conflicts, or search for specific events. It will find contacts, but not add new ones or edit existing information. It will answer some questions, and is much faster and more accurate at serial calculations then I am with a touch screen calculator. It will answer specific questions (“What’s the weather?” “How old is Woody Allen?” “Where can I buy a hot dog?”) It will text, e-mail, create reminders, make a note, schedule (with issues), find a contact and map the way to that contact’s location, calculate, suggest restaurants, and search the web. It sets alarms more quickly and efficiently then any alarm clock with a simple, “Wake me at 7.” It will read texts aloud, but not e-mails. Sometimes it speaks and sometimes it shows. It is fairly quick to say: “I can’t help you with that.” It will play a specific song or playlist from the iPhone’s library. I asked Siri, “At 8:05, ‘play Horse With No Name.” Siri ignored the time request and began playing the song, I asked it to stop, and it replied, “Ok, I will play Stop! In The Name of Love,” and it did.

Siri does not interface with other Apps, and so it can’t be used with my billing software, medical apps, to post to Facebook or Twitter, and sadly, it absolutely insists that Shrink Rap is spelled Shrink Wrap, something I have unable to correct. At times, the system has gone down and Siri has been unable to connect with the network, but I suppose even human personal assistants call in sick.

What about for actual psychiatric uses, how does Siri fare? I asked Siri for a referral to a psychiatrist and it gave 15 listings, “fairly close to you.” One was a psychologist (Siri!), several were the names of hospitals, and for unclear reasons, the Maryland State Government Academic Services was among the listings. I was not among the psychiatrists listed, and I was certainly the closest to me at the time I asked. If the user wants to jump off a bridge, Siri gives a list of bridges in the vicinity – probably not what the patient’s psychiatrist might hope for.

Others are using Siri to answer more existential questions. Dr. Robert Roca, vice president of medical affairs at Sheppard Pratt Hospital has found Siri to be helpful in finding the meaning of life. “When I asked, she made some comment about a play where nothing happens,” Dr. Roca wrote. And when I asked Siri the meaning of life, it replied, “All evidence to date suggests chocolate,” leading me to wonder if Siri knows something about my psyche as compared to Dr. Roca’s.

Dr. Paul Nestadt, a psychiatry resident at Johns Hopkins Hospital, states: “Siri’s psychiatric training is somewhat lacking, although she does have a very analytical philosophy when it comes to psychotherapy. A patient can talk to her for hours without her making any interpretations. I did find myself experiencing some transference with her, demanding things from her with the same impatience I had with my mother as a small child.”

A personal assistant? Not quite. The comprehension/dictation system needs to be much better, as does the interface with other iPhone apps. Oh, but it is a lot of fun. Siri, please submit this article.

<[QM]>—Dinah Miller, M.D.

If you are a health professional and would like to comment on this article, please register with Clinical Psychiatry News. If you are already registered, please log in to comment. You are also welcome to join the discussion on Shrink Rap -- go to the November 16, 2011 post titled “Technology and the Shrink.”

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

In 1938, the residents of Grovers Mills, N.J., were horrified to hear radio news reports that aliens, presumably from Mars, had landed on their countryside and were invading the Earth. In spite of Orson Welles’ introduction that the radio show was pure fiction, the pseudo-news bulletins caused panic in local residents who had either missed the warnings or were taken in by the realistic nature of the reports. In the pre-World War II climate of fear, news of an invasion was quite believable.

Now with the advent of Facebook, blogs, and Twitter, news – or pseudonews – can spread even faster than alien invaders and links to cute cat videos. News about serious world events like the death of Osama bin Laden, the 9-11 attacks, or revolutions in Arabic countries can spread within minutes. Social media aggregation sites like Storify.com and Scoop.it let individuals become news curators by collecting video clips, pictures, tweets, and news reports about a topic on a single web page. We now have the tools to create anxiety, fear, and confusion on an exponential scale, while readers lose the ability to assure the accuracy of what they see and read.

What does this mean for psychiatry, and forensic psychiatry in particular? Let’s look at a list of tweets from one day in the life of this writer, pulled out using the hashtags “forensic” and “psychiatry”:

• Psychiatric care lacking before stabbing

• Hospital overmedicated and mistreated man

• Man accused of killing girlfriend and fetus to use insanity defense

• Man institutionalized for murdering father now charged with brutalizing puppy

• Killer of three acquitted by insanity to walk free again

• Insanity cases cause hospital to overflow

If all you knew about forensic psychiatry was what you read on Twitter, you would think we were filling the streets with evil weapon-wielding overmedicated zombies. The traditional media isn’t much better. Recently, at the American Academy of Psychiatry and Law conference, there was a poster presentation of a study done using news reports from the New York Times, the Los Angeles Times, USA Today and Fox News. The researchers found that of all the stories involving violence and the mentally ill, less than 5% mentioned accurate facts about the dangerousness of psychiatric patients. Apparently, the traditional media remembered what Orson Welles discovered: You can heighten the dramatic effect of a story by overlooking reality.

This information is also read by our patients and their families. While some of Orson Welles’ listeners sued ABC for the injuries caused by the War of the Worlds broadcast, today’s patients have no remedy for the stigma these stories create. Mental health professionals can confront this biased journalism through involvement in social media, by reminding the public about the real facts about violence: That psychiatric patients are more likely to be victims of violence than perpetrators, that they are more likely to be violent against themselves than against others, and that insanity acquittees have recidivism rates substantially lower than non-mentally ill offenders. This information can be repeated (and retweeted) as often as needed. Eventually, the general public may accept that the aliens have not landed.

<[QM]>—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

In 1938, the residents of Grovers Mills, N.J., were horrified to hear radio news reports that aliens, presumably from Mars, had landed on their countryside and were invading the Earth. In spite of Orson Welles’ introduction that the radio show was pure fiction, the pseudo-news bulletins caused panic in local residents who had either missed the warnings or were taken in by the realistic nature of the reports. In the pre-World War II climate of fear, news of an invasion was quite believable.

Now with the advent of Facebook, blogs, and Twitter, news – or pseudonews – can spread even faster than alien invaders and links to cute cat videos. News about serious world events like the death of Osama bin Laden, the 9-11 attacks, or revolutions in Arabic countries can spread within minutes. Social media aggregation sites like Storify.com and Scoop.it let individuals become news curators by collecting video clips, pictures, tweets, and news reports about a topic on a single web page. We now have the tools to create anxiety, fear, and confusion on an exponential scale, while readers lose the ability to assure the accuracy of what they see and read.

What does this mean for psychiatry, and forensic psychiatry in particular? Let’s look at a list of tweets from one day in the life of this writer, pulled out using the hashtags “forensic” and “psychiatry”:

• Psychiatric care lacking before stabbing

• Hospital overmedicated and mistreated man

• Man accused of killing girlfriend and fetus to use insanity defense

• Man institutionalized for murdering father now charged with brutalizing puppy

• Killer of three acquitted by insanity to walk free again

• Insanity cases cause hospital to overflow

If all you knew about forensic psychiatry was what you read on Twitter, you would think we were filling the streets with evil weapon-wielding overmedicated zombies. The traditional media isn’t much better. Recently, at the American Academy of Psychiatry and Law conference, there was a poster presentation of a study done using news reports from the New York Times, the Los Angeles Times, USA Today and Fox News. The researchers found that of all the stories involving violence and the mentally ill, less than 5% mentioned accurate facts about the dangerousness of psychiatric patients. Apparently, the traditional media remembered what Orson Welles discovered: You can heighten the dramatic effect of a story by overlooking reality.

This information is also read by our patients and their families. While some of Orson Welles’ listeners sued ABC for the injuries caused by the War of the Worlds broadcast, today’s patients have no remedy for the stigma these stories create. Mental health professionals can confront this biased journalism through involvement in social media, by reminding the public about the real facts about violence: That psychiatric patients are more likely to be victims of violence than perpetrators, that they are more likely to be violent against themselves than against others, and that insanity acquittees have recidivism rates substantially lower than non-mentally ill offenders. This information can be repeated (and retweeted) as often as needed. Eventually, the general public may accept that the aliens have not landed.

<[QM]>—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

In 1938, the residents of Grovers Mills, N.J., were horrified to hear radio news reports that aliens, presumably from Mars, had landed on their countryside and were invading the Earth. In spite of Orson Welles’ introduction that the radio show was pure fiction, the pseudo-news bulletins caused panic in local residents who had either missed the warnings or were taken in by the realistic nature of the reports. In the pre-World War II climate of fear, news of an invasion was quite believable.

Now with the advent of Facebook, blogs, and Twitter, news – or pseudonews – can spread even faster than alien invaders and links to cute cat videos. News about serious world events like the death of Osama bin Laden, the 9-11 attacks, or revolutions in Arabic countries can spread within minutes. Social media aggregation sites like Storify.com and Scoop.it let individuals become news curators by collecting video clips, pictures, tweets, and news reports about a topic on a single web page. We now have the tools to create anxiety, fear, and confusion on an exponential scale, while readers lose the ability to assure the accuracy of what they see and read.

What does this mean for psychiatry, and forensic psychiatry in particular? Let’s look at a list of tweets from one day in the life of this writer, pulled out using the hashtags “forensic” and “psychiatry”:

• Psychiatric care lacking before stabbing

• Hospital overmedicated and mistreated man

• Man accused of killing girlfriend and fetus to use insanity defense

• Man institutionalized for murdering father now charged with brutalizing puppy

• Killer of three acquitted by insanity to walk free again

• Insanity cases cause hospital to overflow

If all you knew about forensic psychiatry was what you read on Twitter, you would think we were filling the streets with evil weapon-wielding overmedicated zombies. The traditional media isn’t much better. Recently, at the American Academy of Psychiatry and Law conference, there was a poster presentation of a study done using news reports from the New York Times, the Los Angeles Times, USA Today and Fox News. The researchers found that of all the stories involving violence and the mentally ill, less than 5% mentioned accurate facts about the dangerousness of psychiatric patients. Apparently, the traditional media remembered what Orson Welles discovered: You can heighten the dramatic effect of a story by overlooking reality.

This information is also read by our patients and their families. While some of Orson Welles’ listeners sued ABC for the injuries caused by the War of the Worlds broadcast, today’s patients have no remedy for the stigma these stories create. Mental health professionals can confront this biased journalism through involvement in social media, by reminding the public about the real facts about violence: That psychiatric patients are more likely to be victims of violence than perpetrators, that they are more likely to be violent against themselves than against others, and that insanity acquittees have recidivism rates substantially lower than non-mentally ill offenders. This information can be repeated (and retweeted) as often as needed. Eventually, the general public may accept that the aliens have not landed.

<[QM]>—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

It’s pretty impressive how tablet computers, particularly the iPad, have quickly become the must-have gizmo among physicians. I think it’s the portability, usability, and battery life that have made it so useful. As electronic health records (EHRs) are increasingly designed to run on the iPad platform, this partnership will become the doctor’s new black bag.

This is the first portable computing device that truly will run all day without worrying about it dying in the afternoon. The thinness and light weight make it something you don’t even have to think about when it comes time to leave the house or office to go to a meeting or appointment. With a 4-pound laptop, I’ll give it some thought if the utility outweighs the inconvenience of carrying it around. With an iPad, I sometimes have to check that I have it with me because it is so light and slim. This is what makes it easy to take on rounds or have with you when seeing patients.

So these characteristics enable its usefulness, while its usability and numerous apps are what make it sprint past the others. I’ve seen a 3-year old pick it up and quickly start interacting with it, making it easy to use for even the most computer-phobic physician. It’s ready communication abilities – texting, e-mail, phone (via VoiP, like Skype or Google Voice), and web tools like Twitter and Facebook -- make it a handy communication tool, though often a smartphone will take over for these functions.

The numerous medical apps are particularly useful. Epocrates and Medscape help you look up medications and drug interactions. I also keep Stat ICD-9 and Stat E&M to look up codes (a necessity for hospital-based psychiatry). I have Dragon Recorder to dictate when I’m away from my MacBook, where I have Dragon MacDictate installed (works great). Keynote is great for viewing and creating presentations. GoTasks syncs with my Google account for to-do lists. And I also have Citrix, allowing me to log in to my hospital’s EHR to access patient charts, and enter orders and even notes.

There are many other great apps out there for the psychiatrist, though I’ve only used a couple. There is a free PHQ-9 tool, STAT Depression Screener, which is basic and has some limitations, such as providing a “provisional diagnosis” of, say, “Major depression, moderately severe”) and insufficient response to the self-harm question. It also has the MDQ, as well. It appears to be written more for a clinician than for a patient.

One of the most well-used apps, with over 400 reviews on iTunes, is the free My Mood Monitor app, aka M3. The current version of the app is called “depressioncheck.” This one is exceptionally well-done and is designed for the patient. It uses a published, validated, 3-minute, 27-item tool to assess risk for depression, bipolar, and anxiety, including PTSD. Patients are using it weekly to monitor symptoms and report to their provider. Another version of it can be bought by a physician, with codes given out to patients for them to monitor their symptoms, which are reported back to a secure web portal that the physician has access to. The patient tracking screen is very intuitive, with a graphic display for symptoms. Unfortunately, there has not been an update for iOS5 and the app crashes now if you have the latest Apple operating mobile system. The web version is mymoodmonitor.com. (Disclosure: I’ve known the author for the past year and have provided suggestions to improve the function.)

The other big area for iPad apps is for EHRs. There are a number of EHR apps that are mobile extensions of a more robust EHR that you might have installed in your office or hospital. Examples are Epic Canto, Epocrates EHR, and Allscripts Remote. The killer app in this area may be a self-contained EHR that is entirely iPad based but also accessible through a secure web connection. The APA will soon have a way for members to rate their experience with different EHRs, including iPad EHRs. This will help those of us who are just starting to think about moving off paper. For others, the risks of going electronic may still appear to be greater than the benefits.

I’d like to hear about other apps that psychiatrists have found to be useful for their “electronic black bag.” Please feel to add your experiences in the Comments section. (Next week, Dinah will talk about her love affair with Siri.)

<[QM—Steven Roy Daviss, M.D., DFAPA

Dr. Daviss is chair of the department of psychiatry at Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. He is available on Twitter @HITshrink on Twitter and on the Shrink Rap blog.

It’s pretty impressive how tablet computers, particularly the iPad, have quickly become the must-have gizmo among physicians. I think it’s the portability, usability, and battery life that have made it so useful. As electronic health records (EHRs) are increasingly designed to run on the iPad platform, this partnership will become the doctor’s new black bag.

This is the first portable computing device that truly will run all day without worrying about it dying in the afternoon. The thinness and light weight make it something you don’t even have to think about when it comes time to leave the house or office to go to a meeting or appointment. With a 4-pound laptop, I’ll give it some thought if the utility outweighs the inconvenience of carrying it around. With an iPad, I sometimes have to check that I have it with me because it is so light and slim. This is what makes it easy to take on rounds or have with you when seeing patients.

So these characteristics enable its usefulness, while its usability and numerous apps are what make it sprint past the others. I’ve seen a 3-year old pick it up and quickly start interacting with it, making it easy to use for even the most computer-phobic physician. It’s ready communication abilities – texting, e-mail, phone (via VoiP, like Skype or Google Voice), and web tools like Twitter and Facebook -- make it a handy communication tool, though often a smartphone will take over for these functions.

The numerous medical apps are particularly useful. Epocrates and Medscape help you look up medications and drug interactions. I also keep Stat ICD-9 and Stat E&M to look up codes (a necessity for hospital-based psychiatry). I have Dragon Recorder to dictate when I’m away from my MacBook, where I have Dragon MacDictate installed (works great). Keynote is great for viewing and creating presentations. GoTasks syncs with my Google account for to-do lists. And I also have Citrix, allowing me to log in to my hospital’s EHR to access patient charts, and enter orders and even notes.

There are many other great apps out there for the psychiatrist, though I’ve only used a couple. There is a free PHQ-9 tool, STAT Depression Screener, which is basic and has some limitations, such as providing a “provisional diagnosis” of, say, “Major depression, moderately severe”) and insufficient response to the self-harm question. It also has the MDQ, as well. It appears to be written more for a clinician than for a patient.

One of the most well-used apps, with over 400 reviews on iTunes, is the free My Mood Monitor app, aka M3. The current version of the app is called “depressioncheck.” This one is exceptionally well-done and is designed for the patient. It uses a published, validated, 3-minute, 27-item tool to assess risk for depression, bipolar, and anxiety, including PTSD. Patients are using it weekly to monitor symptoms and report to their provider. Another version of it can be bought by a physician, with codes given out to patients for them to monitor their symptoms, which are reported back to a secure web portal that the physician has access to. The patient tracking screen is very intuitive, with a graphic display for symptoms. Unfortunately, there has not been an update for iOS5 and the app crashes now if you have the latest Apple operating mobile system. The web version is mymoodmonitor.com. (Disclosure: I’ve known the author for the past year and have provided suggestions to improve the function.)

The other big area for iPad apps is for EHRs. There are a number of EHR apps that are mobile extensions of a more robust EHR that you might have installed in your office or hospital. Examples are Epic Canto, Epocrates EHR, and Allscripts Remote. The killer app in this area may be a self-contained EHR that is entirely iPad based but also accessible through a secure web connection. The APA will soon have a way for members to rate their experience with different EHRs, including iPad EHRs. This will help those of us who are just starting to think about moving off paper. For others, the risks of going electronic may still appear to be greater than the benefits.

I’d like to hear about other apps that psychiatrists have found to be useful for their “electronic black bag.” Please feel to add your experiences in the Comments section. (Next week, Dinah will talk about her love affair with Siri.)

<[QM—Steven Roy Daviss, M.D., DFAPA

Dr. Daviss is chair of the department of psychiatry at Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. He is available on Twitter @HITshrink on Twitter and on the Shrink Rap blog.

It’s pretty impressive how tablet computers, particularly the iPad, have quickly become the must-have gizmo among physicians. I think it’s the portability, usability, and battery life that have made it so useful. As electronic health records (EHRs) are increasingly designed to run on the iPad platform, this partnership will become the doctor’s new black bag.

This is the first portable computing device that truly will run all day without worrying about it dying in the afternoon. The thinness and light weight make it something you don’t even have to think about when it comes time to leave the house or office to go to a meeting or appointment. With a 4-pound laptop, I’ll give it some thought if the utility outweighs the inconvenience of carrying it around. With an iPad, I sometimes have to check that I have it with me because it is so light and slim. This is what makes it easy to take on rounds or have with you when seeing patients.

So these characteristics enable its usefulness, while its usability and numerous apps are what make it sprint past the others. I’ve seen a 3-year old pick it up and quickly start interacting with it, making it easy to use for even the most computer-phobic physician. It’s ready communication abilities – texting, e-mail, phone (via VoiP, like Skype or Google Voice), and web tools like Twitter and Facebook -- make it a handy communication tool, though often a smartphone will take over for these functions.

The numerous medical apps are particularly useful. Epocrates and Medscape help you look up medications and drug interactions. I also keep Stat ICD-9 and Stat E&M to look up codes (a necessity for hospital-based psychiatry). I have Dragon Recorder to dictate when I’m away from my MacBook, where I have Dragon MacDictate installed (works great). Keynote is great for viewing and creating presentations. GoTasks syncs with my Google account for to-do lists. And I also have Citrix, allowing me to log in to my hospital’s EHR to access patient charts, and enter orders and even notes.

There are many other great apps out there for the psychiatrist, though I’ve only used a couple. There is a free PHQ-9 tool, STAT Depression Screener, which is basic and has some limitations, such as providing a “provisional diagnosis” of, say, “Major depression, moderately severe”) and insufficient response to the self-harm question. It also has the MDQ, as well. It appears to be written more for a clinician than for a patient.

One of the most well-used apps, with over 400 reviews on iTunes, is the free My Mood Monitor app, aka M3. The current version of the app is called “depressioncheck.” This one is exceptionally well-done and is designed for the patient. It uses a published, validated, 3-minute, 27-item tool to assess risk for depression, bipolar, and anxiety, including PTSD. Patients are using it weekly to monitor symptoms and report to their provider. Another version of it can be bought by a physician, with codes given out to patients for them to monitor their symptoms, which are reported back to a secure web portal that the physician has access to. The patient tracking screen is very intuitive, with a graphic display for symptoms. Unfortunately, there has not been an update for iOS5 and the app crashes now if you have the latest Apple operating mobile system. The web version is mymoodmonitor.com. (Disclosure: I’ve known the author for the past year and have provided suggestions to improve the function.)

The other big area for iPad apps is for EHRs. There are a number of EHR apps that are mobile extensions of a more robust EHR that you might have installed in your office or hospital. Examples are Epic Canto, Epocrates EHR, and Allscripts Remote. The killer app in this area may be a self-contained EHR that is entirely iPad based but also accessible through a secure web connection. The APA will soon have a way for members to rate their experience with different EHRs, including iPad EHRs. This will help those of us who are just starting to think about moving off paper. For others, the risks of going electronic may still appear to be greater than the benefits.

I’d like to hear about other apps that psychiatrists have found to be useful for their “electronic black bag.” Please feel to add your experiences in the Comments section. (Next week, Dinah will talk about her love affair with Siri.)

<[QM—Steven Roy Daviss, M.D., DFAPA

Dr. Daviss is chair of the department of psychiatry at Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. He is available on Twitter @HITshrink on Twitter and on the Shrink Rap blog.

Recently, the news was filled with the story of Terry Thompson, an Ohio exotic animal preserve owner who committed suicide after turning loose his bears, tigers, lions and other animals he cared for. Apparently, he was suffering from financial and legal problems, his wife had recently left him, and he had been incarcerated for a handgun charge. Nearly 50 animals were released, and almost all were killed by police to protect public safety.

Public opinion came out strongly in favor of passing stronger laws to prohibit ownership of exotic pets. People mourned the deaths of the animals, some of which were endangered species. Former zoo director Jack Hanna spoke publicly about his grief over the animals’ deaths and the need to be more aggressive about wildlife regulation.

People have speculated about Thompson’s motivation for releasing the animals. Maybe he did it because he wanted to wreak havoc on the community, a kind of animal proxy spree-killing. Maybe he did it because he couldn’t care for them anymore and couldn’t bear to give them away. More disturbingly, there were some suggestions that he released the animals hoping they would kill him---suicide by tiger. Almost all of this speculation has been followed up by a single common sentiment: “Why couldn't he have just killed himself and left the animals alone?”

This reaction resonated with me, because I’ve treated people who have killed others in the course of a suicide attempt, killing a spouse or a child or an aging parent. I know that sometimes the only thing holding a clinically depressed person back from the brink of death is the obligation to care for a dependent living creature. Unfortunately, clinically depressed caregivers may believe they are incompetent nurturers or even a burden on those they are caring for. They may believe that they are causing their loved ones to suffer, and that murder is necessary to end that suffering. While this makes no sense to the outside observer, it is consistent with the dark world view of a severely depressed person.

There is little public sympathy for murderers, even those who kill mistakenly due to mental illness. I am reminded of a statement made in the novel Mount Misery, a darkly humorous novel about psychiatric training by House of God author Stephen Bergman. In Mount Misery, one psychiatrist defined a “citizen” or upstanding patient as one who kills himself before killing his family. I saw this jaded view reflected in the public reaction to the animal caretaker’s death.

I found myself wondering what could have been done differently. Since Thompson had been incarcerated, he could have had access to mental health care. Almost all correctional facilities screen for mental illness and ask questions about suicidal thoughts. Did he tell anyone how he was feeling? Or did things just get worse after his release? Did he even know he had a treatable condition?

Fortunately, there were no other human deaths in this incident, but the loss of a life is lamentable whether that creature has skin, scale, fur, or feathers.

<[QM]>—Annette Hanson, M.D.

 Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Recently, the news was filled with the story of Terry Thompson, an Ohio exotic animal preserve owner who committed suicide after turning loose his bears, tigers, lions and other animals he cared for. Apparently, he was suffering from financial and legal problems, his wife had recently left him, and he had been incarcerated for a handgun charge. Nearly 50 animals were released, and almost all were killed by police to protect public safety.

Public opinion came out strongly in favor of passing stronger laws to prohibit ownership of exotic pets. People mourned the deaths of the animals, some of which were endangered species. Former zoo director Jack Hanna spoke publicly about his grief over the animals’ deaths and the need to be more aggressive about wildlife regulation.

People have speculated about Thompson’s motivation for releasing the animals. Maybe he did it because he wanted to wreak havoc on the community, a kind of animal proxy spree-killing. Maybe he did it because he couldn’t care for them anymore and couldn’t bear to give them away. More disturbingly, there were some suggestions that he released the animals hoping they would kill him---suicide by tiger. Almost all of this speculation has been followed up by a single common sentiment: “Why couldn't he have just killed himself and left the animals alone?”

This reaction resonated with me, because I’ve treated people who have killed others in the course of a suicide attempt, killing a spouse or a child or an aging parent. I know that sometimes the only thing holding a clinically depressed person back from the brink of death is the obligation to care for a dependent living creature. Unfortunately, clinically depressed caregivers may believe they are incompetent nurturers or even a burden on those they are caring for. They may believe that they are causing their loved ones to suffer, and that murder is necessary to end that suffering. While this makes no sense to the outside observer, it is consistent with the dark world view of a severely depressed person.

There is little public sympathy for murderers, even those who kill mistakenly due to mental illness. I am reminded of a statement made in the novel Mount Misery, a darkly humorous novel about psychiatric training by House of God author Stephen Bergman. In Mount Misery, one psychiatrist defined a “citizen” or upstanding patient as one who kills himself before killing his family. I saw this jaded view reflected in the public reaction to the animal caretaker’s death.

I found myself wondering what could have been done differently. Since Thompson had been incarcerated, he could have had access to mental health care. Almost all correctional facilities screen for mental illness and ask questions about suicidal thoughts. Did he tell anyone how he was feeling? Or did things just get worse after his release? Did he even know he had a treatable condition?

Fortunately, there were no other human deaths in this incident, but the loss of a life is lamentable whether that creature has skin, scale, fur, or feathers.

<[QM]>—Annette Hanson, M.D.

 Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Recently, the news was filled with the story of Terry Thompson, an Ohio exotic animal preserve owner who committed suicide after turning loose his bears, tigers, lions and other animals he cared for. Apparently, he was suffering from financial and legal problems, his wife had recently left him, and he had been incarcerated for a handgun charge. Nearly 50 animals were released, and almost all were killed by police to protect public safety.

Public opinion came out strongly in favor of passing stronger laws to prohibit ownership of exotic pets. People mourned the deaths of the animals, some of which were endangered species. Former zoo director Jack Hanna spoke publicly about his grief over the animals’ deaths and the need to be more aggressive about wildlife regulation.

People have speculated about Thompson’s motivation for releasing the animals. Maybe he did it because he wanted to wreak havoc on the community, a kind of animal proxy spree-killing. Maybe he did it because he couldn’t care for them anymore and couldn’t bear to give them away. More disturbingly, there were some suggestions that he released the animals hoping they would kill him---suicide by tiger. Almost all of this speculation has been followed up by a single common sentiment: “Why couldn't he have just killed himself and left the animals alone?”

This reaction resonated with me, because I’ve treated people who have killed others in the course of a suicide attempt, killing a spouse or a child or an aging parent. I know that sometimes the only thing holding a clinically depressed person back from the brink of death is the obligation to care for a dependent living creature. Unfortunately, clinically depressed caregivers may believe they are incompetent nurturers or even a burden on those they are caring for. They may believe that they are causing their loved ones to suffer, and that murder is necessary to end that suffering. While this makes no sense to the outside observer, it is consistent with the dark world view of a severely depressed person.

There is little public sympathy for murderers, even those who kill mistakenly due to mental illness. I am reminded of a statement made in the novel Mount Misery, a darkly humorous novel about psychiatric training by House of God author Stephen Bergman. In Mount Misery, one psychiatrist defined a “citizen” or upstanding patient as one who kills himself before killing his family. I saw this jaded view reflected in the public reaction to the animal caretaker’s death.

I found myself wondering what could have been done differently. Since Thompson had been incarcerated, he could have had access to mental health care. Almost all correctional facilities screen for mental illness and ask questions about suicidal thoughts. Did he tell anyone how he was feeling? Or did things just get worse after his release? Did he even know he had a treatable condition?

Fortunately, there were no other human deaths in this incident, but the loss of a life is lamentable whether that creature has skin, scale, fur, or feathers.

<[QM]>—Annette Hanson, M.D.

 Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Many payers establish cost-control measures for expensive medications, particularly the current crop of branded antipsychotics, like Zyprexa, Abilify, Invega, Latuda, and Saphris. These medications are sometimes over $500 per month when paid at full-price. For most Medicaid payers, these atypical antipsychotics are the most costly drug category they manage, so cutting access to these drugs during these times of state budget cuts becomes an attractive target.

Mechanisms to limit the use of these drugs include formularies, preferred drug lists (PDLs), fail-first policies, tiering strategies, dosage limits, pill count limits, limits based on diagnosis, and prior authorizations. Adding hoops through which the prescriber or patient must jump is known to reduce the utilization of target medications while funneling medication decisions into less costly generic or lower cost drugs. However, these same barriers can also result in increased costs when consumers fail to obtain the prescribed medication, causing them to go without medication and potentially resulting in a relapse that can lead to avoidable ER (emergency room) visits and hospitalizations.

The 2009 study by Joyce West, et al., in Psychiatric Services (“Medicaid Prescription Drug Policies and Medication Access and Continuity: Findings From Ten States”) found that Medicaid patients with medication access problems had 3.6 times the number of adverse events (including ER visits, hospitalization, homelessness, suicidal ideation, and incarceration). States with more stringent cost-control mechanisms were associated with more access problems and more adverse events. Patients who required a prior authorization were three times more likely to have a psychiatric hospitalization and twice as likely to have an ER visit. Those who required the use of a preferred drug list or formulary were 2.3 times more likely to be hospitalized and 1.8 times more likely to have an ER visit.

With the high costs of hospitalization and emergency care, this begs the question of whether the savings produced by these pharmacy management methods are outweighed by the excess costs associated with increased care needed when patients stop taking medications due to access problems. Indeed, each state should ask for independent analyses of their medication claims and inpatient and outpatient utilization data to determine where the greatest benefit lies. Unfortunately, the impression is that short-term, line-item cost reductions are emphasized rather than a system level focus.

In Maryland, where I sit on the Medicaid Pharmacy Program’s Pharmacy & Therapeutics Committee (P&T), we have moved over the past 3 years or so from an open access position (for psychotropics) to one with increasing restrictions based on a preferred drug list (PDL), which now has three tiers. P&T is advisory to the health department, but often accepts our recommendations. There is also a Drug Utilization Review Committee (DUR) that also advises on drug utilization issues. Up until last month, the minutes from these committees were not made available on their website, but now contain the 2010 meetings for both P&T and DUR. Most states have their full minutes posted. Each of the meetings are public and permit limited public testimony (except for DUR, which does not accept public input).

The mechanism we now have in place to limit use of antipsychotics is complex, but I’ll try to explain it. Maryland Medicaid now has two classes of antipsychotic medications in its formulary, Preferred and Nonpreferred. Drugs that are Preferred are on the PDL (Preferred Drug List). The PDL is split into Tier 1 and Tier 2 categories: Tier 1 meds never require a prior authorization. Tier 1 currently includes older generic antipsychotics, generic risperidone and clozapine, Fanapt, Geodon, and Risperdal Consta depot injection. Tier 2 includes only Zyprexa and Abilify. Tier 3 includes Invega, Latuda, Seroquel XR, Saphris, Invega Sustenna depot injection, and Zyprexa Relprevv depot injection.

Tier 1 drugs never require a prior authorization. Patients who are considered “drug-naïve” -- and so have never been on an antipsychotic before and should have fewer constraints about which drug to first try -- must be tried on a Tier 1 medication for at least 6 weeks (i.e., has filled at least two prescriptions) before trying a Tier 2 drug. Tier 2 medications do not require a prior authorization as long the patient has previously been on a Tier 1 drug for 6 weeks within the most recent 120 days. This 120-day period is the “look-back period.” If you want to try a Tier 2 drug on a “drug-naïve” patient, a prior authorization must be completed. (As noted above, requiring a prior authorization is more likely to be associated with delays in obtaining medications, sometimes causing patients to stop medications, potentially resulting in increased ED visits and hospitalizations.) Tier 3 medications -- also called Nonpreferred drugs -- always require a prior authorization.

A prior authorization involves a phone call or a fax, and is nearly always approved when requested, which is less stringent than many states. However, web-based authorizations are not available. The phone call must be made by the prescriber and takes about 5-8 minutes. This is sometimes onerous for busy clinicians, who may instead choose to complete the fax form. The faxed authorization takes up to 24 hours to complete so the patient who goes to the pharmacy on the same day may be told that the medication has not been authorized.

The look-back period is key in determining who is considered to be “drug-naïve.” The P&T committee members originally developed the concept of “drug-naïve” to limit the need to obtain prior authorizations only for those patients who had never been on antipsychotics. The idea was that those who have a history of taking antipsychotics -- including those who did particularly well or poorly on a Tier 1 drug or those who were unable to tolerate these drugs due to side effects -- would not have to go back and take a Tier 1 medication again and could get a “free pass” to get Tier 2 medications without jumping through the hoop of obtaining a prior authorization. This concept was undermined by adding a rule that patients who are “drug-naïve” are defined as such by whether they had outpatient prescriptions filled during the “look-back period.”

The look-back period for determining whether someone is “drug-naïve” is now 120 days. Here is the effect of this scheme: If a patient does not get two prescriptions filled (actually, a total of 42 days worth of medications) during the most recent 120 days, then the patient’s status reverts back to “drug-naïve” and the patient has to start all over.  So, if a patient is non-compliant for 4 months, or receives samples for 4 months, or is hospitalized or imprisoned for 4 months, and so does not get at least 2 prescriptions filled during that time period, then the patient now becomes “drug-naïve” -- even if the patient has failed medication trials or has had unacceptable side effects in the past. The patient has to either go through the Tier 1 drugs again OR go through the prior authorization process again.

This does not make clinical sense. The Kaiser pharmacist on the committee indicated that they look back as far as they have data to make such decisions. So the committee unanimously voted to extend the look-back period to 2 years in August 2010, but the DUR committee rejected this as unnecessary and costly.

It is hoped that an independent group will soon be able to review the pharmacy and inpatient and outpatient databases to analyze the downstream effects of these medication access decisions. In an era of cost containment and evidence-based medicine, we all want to be sure that states are not being penny-wise and pound-foolish.

<[QM—Steven Roy Daviss, M.D., DFAPA

Dr. Daviss is co-author of Shrink Rap: Three Psychiatrists Explain Their Work, chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, and serves on the Maryland Medicaid Pharmacy Program’s Pharmacy and Therapeutics Committee. He can be reached on Google Plus, Twitter, and Facebook.

Many payers establish cost-control measures for expensive medications, particularly the current crop of branded antipsychotics, like Zyprexa, Abilify, Invega, Latuda, and Saphris. These medications are sometimes over $500 per month when paid at full-price. For most Medicaid payers, these atypical antipsychotics are the most costly drug category they manage, so cutting access to these drugs during these times of state budget cuts becomes an attractive target.

Mechanisms to limit the use of these drugs include formularies, preferred drug lists (PDLs), fail-first policies, tiering strategies, dosage limits, pill count limits, limits based on diagnosis, and prior authorizations. Adding hoops through which the prescriber or patient must jump is known to reduce the utilization of target medications while funneling medication decisions into less costly generic or lower cost drugs. However, these same barriers can also result in increased costs when consumers fail to obtain the prescribed medication, causing them to go without medication and potentially resulting in a relapse that can lead to avoidable ER (emergency room) visits and hospitalizations.

The 2009 study by Joyce West, et al., in Psychiatric Services (“Medicaid Prescription Drug Policies and Medication Access and Continuity: Findings From Ten States”) found that Medicaid patients with medication access problems had 3.6 times the number of adverse events (including ER visits, hospitalization, homelessness, suicidal ideation, and incarceration). States with more stringent cost-control mechanisms were associated with more access problems and more adverse events. Patients who required a prior authorization were three times more likely to have a psychiatric hospitalization and twice as likely to have an ER visit. Those who required the use of a preferred drug list or formulary were 2.3 times more likely to be hospitalized and 1.8 times more likely to have an ER visit.

With the high costs of hospitalization and emergency care, this begs the question of whether the savings produced by these pharmacy management methods are outweighed by the excess costs associated with increased care needed when patients stop taking medications due to access problems. Indeed, each state should ask for independent analyses of their medication claims and inpatient and outpatient utilization data to determine where the greatest benefit lies. Unfortunately, the impression is that short-term, line-item cost reductions are emphasized rather than a system level focus.

In Maryland, where I sit on the Medicaid Pharmacy Program’s Pharmacy & Therapeutics Committee (P&T), we have moved over the past 3 years or so from an open access position (for psychotropics) to one with increasing restrictions based on a preferred drug list (PDL), which now has three tiers. P&T is advisory to the health department, but often accepts our recommendations. There is also a Drug Utilization Review Committee (DUR) that also advises on drug utilization issues. Up until last month, the minutes from these committees were not made available on their website, but now contain the 2010 meetings for both P&T and DUR. Most states have their full minutes posted. Each of the meetings are public and permit limited public testimony (except for DUR, which does not accept public input).

The mechanism we now have in place to limit use of antipsychotics is complex, but I’ll try to explain it. Maryland Medicaid now has two classes of antipsychotic medications in its formulary, Preferred and Nonpreferred. Drugs that are Preferred are on the PDL (Preferred Drug List). The PDL is split into Tier 1 and Tier 2 categories: Tier 1 meds never require a prior authorization. Tier 1 currently includes older generic antipsychotics, generic risperidone and clozapine, Fanapt, Geodon, and Risperdal Consta depot injection. Tier 2 includes only Zyprexa and Abilify. Tier 3 includes Invega, Latuda, Seroquel XR, Saphris, Invega Sustenna depot injection, and Zyprexa Relprevv depot injection.

Tier 1 drugs never require a prior authorization. Patients who are considered “drug-naïve” -- and so have never been on an antipsychotic before and should have fewer constraints about which drug to first try -- must be tried on a Tier 1 medication for at least 6 weeks (i.e., has filled at least two prescriptions) before trying a Tier 2 drug. Tier 2 medications do not require a prior authorization as long the patient has previously been on a Tier 1 drug for 6 weeks within the most recent 120 days. This 120-day period is the “look-back period.” If you want to try a Tier 2 drug on a “drug-naïve” patient, a prior authorization must be completed. (As noted above, requiring a prior authorization is more likely to be associated with delays in obtaining medications, sometimes causing patients to stop medications, potentially resulting in increased ED visits and hospitalizations.) Tier 3 medications -- also called Nonpreferred drugs -- always require a prior authorization.

A prior authorization involves a phone call or a fax, and is nearly always approved when requested, which is less stringent than many states. However, web-based authorizations are not available. The phone call must be made by the prescriber and takes about 5-8 minutes. This is sometimes onerous for busy clinicians, who may instead choose to complete the fax form. The faxed authorization takes up to 24 hours to complete so the patient who goes to the pharmacy on the same day may be told that the medication has not been authorized.

The look-back period is key in determining who is considered to be “drug-naïve.” The P&T committee members originally developed the concept of “drug-naïve” to limit the need to obtain prior authorizations only for those patients who had never been on antipsychotics. The idea was that those who have a history of taking antipsychotics -- including those who did particularly well or poorly on a Tier 1 drug or those who were unable to tolerate these drugs due to side effects -- would not have to go back and take a Tier 1 medication again and could get a “free pass” to get Tier 2 medications without jumping through the hoop of obtaining a prior authorization. This concept was undermined by adding a rule that patients who are “drug-naïve” are defined as such by whether they had outpatient prescriptions filled during the “look-back period.”

The look-back period for determining whether someone is “drug-naïve” is now 120 days. Here is the effect of this scheme: If a patient does not get two prescriptions filled (actually, a total of 42 days worth of medications) during the most recent 120 days, then the patient’s status reverts back to “drug-naïve” and the patient has to start all over.  So, if a patient is non-compliant for 4 months, or receives samples for 4 months, or is hospitalized or imprisoned for 4 months, and so does not get at least 2 prescriptions filled during that time period, then the patient now becomes “drug-naïve” -- even if the patient has failed medication trials or has had unacceptable side effects in the past. The patient has to either go through the Tier 1 drugs again OR go through the prior authorization process again.

This does not make clinical sense. The Kaiser pharmacist on the committee indicated that they look back as far as they have data to make such decisions. So the committee unanimously voted to extend the look-back period to 2 years in August 2010, but the DUR committee rejected this as unnecessary and costly.

It is hoped that an independent group will soon be able to review the pharmacy and inpatient and outpatient databases to analyze the downstream effects of these medication access decisions. In an era of cost containment and evidence-based medicine, we all want to be sure that states are not being penny-wise and pound-foolish.

<[QM—Steven Roy Daviss, M.D., DFAPA

Dr. Daviss is co-author of Shrink Rap: Three Psychiatrists Explain Their Work, chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, and serves on the Maryland Medicaid Pharmacy Program’s Pharmacy and Therapeutics Committee. He can be reached on Google Plus, Twitter, and Facebook.

Many payers establish cost-control measures for expensive medications, particularly the current crop of branded antipsychotics, like Zyprexa, Abilify, Invega, Latuda, and Saphris. These medications are sometimes over $500 per month when paid at full-price. For most Medicaid payers, these atypical antipsychotics are the most costly drug category they manage, so cutting access to these drugs during these times of state budget cuts becomes an attractive target.

Mechanisms to limit the use of these drugs include formularies, preferred drug lists (PDLs), fail-first policies, tiering strategies, dosage limits, pill count limits, limits based on diagnosis, and prior authorizations. Adding hoops through which the prescriber or patient must jump is known to reduce the utilization of target medications while funneling medication decisions into less costly generic or lower cost drugs. However, these same barriers can also result in increased costs when consumers fail to obtain the prescribed medication, causing them to go without medication and potentially resulting in a relapse that can lead to avoidable ER (emergency room) visits and hospitalizations.

The 2009 study by Joyce West, et al., in Psychiatric Services (“Medicaid Prescription Drug Policies and Medication Access and Continuity: Findings From Ten States”) found that Medicaid patients with medication access problems had 3.6 times the number of adverse events (including ER visits, hospitalization, homelessness, suicidal ideation, and incarceration). States with more stringent cost-control mechanisms were associated with more access problems and more adverse events. Patients who required a prior authorization were three times more likely to have a psychiatric hospitalization and twice as likely to have an ER visit. Those who required the use of a preferred drug list or formulary were 2.3 times more likely to be hospitalized and 1.8 times more likely to have an ER visit.

With the high costs of hospitalization and emergency care, this begs the question of whether the savings produced by these pharmacy management methods are outweighed by the excess costs associated with increased care needed when patients stop taking medications due to access problems. Indeed, each state should ask for independent analyses of their medication claims and inpatient and outpatient utilization data to determine where the greatest benefit lies. Unfortunately, the impression is that short-term, line-item cost reductions are emphasized rather than a system level focus.

In Maryland, where I sit on the Medicaid Pharmacy Program’s Pharmacy & Therapeutics Committee (P&T), we have moved over the past 3 years or so from an open access position (for psychotropics) to one with increasing restrictions based on a preferred drug list (PDL), which now has three tiers. P&T is advisory to the health department, but often accepts our recommendations. There is also a Drug Utilization Review Committee (DUR) that also advises on drug utilization issues. Up until last month, the minutes from these committees were not made available on their website, but now contain the 2010 meetings for both P&T and DUR. Most states have their full minutes posted. Each of the meetings are public and permit limited public testimony (except for DUR, which does not accept public input).

The mechanism we now have in place to limit use of antipsychotics is complex, but I’ll try to explain it. Maryland Medicaid now has two classes of antipsychotic medications in its formulary, Preferred and Nonpreferred. Drugs that are Preferred are on the PDL (Preferred Drug List). The PDL is split into Tier 1 and Tier 2 categories: Tier 1 meds never require a prior authorization. Tier 1 currently includes older generic antipsychotics, generic risperidone and clozapine, Fanapt, Geodon, and Risperdal Consta depot injection. Tier 2 includes only Zyprexa and Abilify. Tier 3 includes Invega, Latuda, Seroquel XR, Saphris, Invega Sustenna depot injection, and Zyprexa Relprevv depot injection.

Tier 1 drugs never require a prior authorization. Patients who are considered “drug-naïve” -- and so have never been on an antipsychotic before and should have fewer constraints about which drug to first try -- must be tried on a Tier 1 medication for at least 6 weeks (i.e., has filled at least two prescriptions) before trying a Tier 2 drug. Tier 2 medications do not require a prior authorization as long the patient has previously been on a Tier 1 drug for 6 weeks within the most recent 120 days. This 120-day period is the “look-back period.” If you want to try a Tier 2 drug on a “drug-naïve” patient, a prior authorization must be completed. (As noted above, requiring a prior authorization is more likely to be associated with delays in obtaining medications, sometimes causing patients to stop medications, potentially resulting in increased ED visits and hospitalizations.) Tier 3 medications -- also called Nonpreferred drugs -- always require a prior authorization.

A prior authorization involves a phone call or a fax, and is nearly always approved when requested, which is less stringent than many states. However, web-based authorizations are not available. The phone call must be made by the prescriber and takes about 5-8 minutes. This is sometimes onerous for busy clinicians, who may instead choose to complete the fax form. The faxed authorization takes up to 24 hours to complete so the patient who goes to the pharmacy on the same day may be told that the medication has not been authorized.

The look-back period is key in determining who is considered to be “drug-naïve.” The P&T committee members originally developed the concept of “drug-naïve” to limit the need to obtain prior authorizations only for those patients who had never been on antipsychotics. The idea was that those who have a history of taking antipsychotics -- including those who did particularly well or poorly on a Tier 1 drug or those who were unable to tolerate these drugs due to side effects -- would not have to go back and take a Tier 1 medication again and could get a “free pass” to get Tier 2 medications without jumping through the hoop of obtaining a prior authorization. This concept was undermined by adding a rule that patients who are “drug-naïve” are defined as such by whether they had outpatient prescriptions filled during the “look-back period.”

The look-back period for determining whether someone is “drug-naïve” is now 120 days. Here is the effect of this scheme: If a patient does not get two prescriptions filled (actually, a total of 42 days worth of medications) during the most recent 120 days, then the patient’s status reverts back to “drug-naïve” and the patient has to start all over.  So, if a patient is non-compliant for 4 months, or receives samples for 4 months, or is hospitalized or imprisoned for 4 months, and so does not get at least 2 prescriptions filled during that time period, then the patient now becomes “drug-naïve” -- even if the patient has failed medication trials or has had unacceptable side effects in the past. The patient has to either go through the Tier 1 drugs again OR go through the prior authorization process again.

This does not make clinical sense. The Kaiser pharmacist on the committee indicated that they look back as far as they have data to make such decisions. So the committee unanimously voted to extend the look-back period to 2 years in August 2010, but the DUR committee rejected this as unnecessary and costly.

It is hoped that an independent group will soon be able to review the pharmacy and inpatient and outpatient databases to analyze the downstream effects of these medication access decisions. In an era of cost containment and evidence-based medicine, we all want to be sure that states are not being penny-wise and pound-foolish.

<[QM—Steven Roy Daviss, M.D., DFAPA

Dr. Daviss is co-author of Shrink Rap: Three Psychiatrists Explain Their Work, chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, and serves on the Maryland Medicaid Pharmacy Program’s Pharmacy and Therapeutics Committee. He can be reached on Google Plus, Twitter, and Facebook.

Back in the day, manic depressive illness was a diagnosis reserved for those who suffered from discrete episodes of depressed or elevated mood states. We know that people who suffer from this illness, in this way, do better over time if they are treated with mood stabilizers, and patients are often told to remain on medications for life.

Over the past two decades, the diagnosis has expanded to include those patients with hypomanic episodes and chronic mood lability. The diagnosis has become a catch-all category for some patients with impulsivity, irritability, and behavioral dyscontrol, even in the absence of discrete syndromic episodes or prominent mood symptoms. We now talk about bipolar disorder in terms of type I, 2, (or even 3), rapid cycling, mixed states, and we refer to it as a “spectrum” disorder where the lines between anxiety states, attentional problems, personality styles, substance abuse, adolescent turmoil, and sociopathy all blur. In children, the diagnostic criteria are even murkier.

So what’s the problem? Or is there even a problem?

From the perspective of psychiatrists, we’ve lost the ability to communicate about our work with one another and we’ve lost our credibility with the public. The word “bipolar” means something different to everyone, and it’s not uncommon for people to say that psychiatrists over-diagnose, and misdiagnose, and “call everyone bipolar.” Patients will insist they don’t have bipolar disorder because they aren’t doing the things a bipolar neighbor does. Or they may embrace the diagnosis in a way that both defines and explains all of who they are. It’s not uncommon to hear patients say, “I’m bipolar” rather than “I have bipolar disorder” and to offer it up as an explanation.

Many people with these difficulties seem to either feel or behave better if they are treated with medications. It wouldn’t be such a big deal if the diagnosis were not attached to a mandate – or at least a strong recommendation – for lifetime treatment with medications, and if it didn’t bring to mind images of dangerousness, volatility, unpredictability, and perpetual dysfunction.

The truth is that people come to psychiatrists when they are in states of distress, and their ways of suffering don’t always fit neatly into one of the 297 diagnostic categories that DSM-IV-TR identifies. Insurers demand diagnoses (only certain ones, at that) and the unwritten rules of good medicine say it’s not okay to prescribe for a patient based on sheer desperation, yet that is what we sometimes do. We diagnose because diagnosis justifies treatment. Often our interventions work and our patients get better.

The diagnosis of bipolar disorder has come to sound ominous. And yet, the course it will follow is hard to predict. One person may have three or four discrete episodes in as many decades and function quite well otherwise; classic bipolar disorder where we know that mood stabilizers are likely to decrease the number and severity of episodes. Another patient may live in the chaotic upheaval of underachievement, lost jobs, and marital struggle, while a third patient may have symptoms so entrenched with substance abuse and violence that the issue of actual “mood” gets lost in the mix. Consider the young child who throws temper tantrums and is too volatile to remain in a classroom, but who does so much better once he starts medications, or the moody teenager who requires intervention but later outgrows his difficulties. Are we sure these patients all have the same illness? Are we sure they all need lifetime treatment?

Perhaps they are all variants of the same disease and certainly the expansion of the bipolar diagnosis has allowed more patients to access treatment and get help. But we don’t know that all patients captured by the expanded range of bipolar spectrum disorders need the “medicine for the rest of your life,” nor do we know their prognosis – we simply don’t yet have the data to reach these conclusions.

Until we do have answers from long-term studies, perhaps we need to reassess how we think about bipolar disorder, its treatment, and the picture we paint of it to our patients and the public.

Over on our original Shrink Rap blog, I asked our readers to write about how they define bipolar disorder and the comments that came in are more poignant and revealing than anything I could ever write. Please do read them by clicking here and feel free to join in the discussion.

My thanks to Dean McKinnon, M.D., author of Trouble in Mind, who served as my mood disorders expert for this article.

<[QM]>—Dinah Miller, M.D.

If you would like to comment on this article here, please register with Clinical Psychiatry News. If you are already registered, please log in to comment. You are also welcome to join the discussion on Shrink Rap at the post titled “What is Bipolar Disorder?”

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

Back in the day, manic depressive illness was a diagnosis reserved for those who suffered from discrete episodes of depressed or elevated mood states. We know that people who suffer from this illness, in this way, do better over time if they are treated with mood stabilizers, and patients are often told to remain on medications for life.

Over the past two decades, the diagnosis has expanded to include those patients with hypomanic episodes and chronic mood lability. The diagnosis has become a catch-all category for some patients with impulsivity, irritability, and behavioral dyscontrol, even in the absence of discrete syndromic episodes or prominent mood symptoms. We now talk about bipolar disorder in terms of type I, 2, (or even 3), rapid cycling, mixed states, and we refer to it as a “spectrum” disorder where the lines between anxiety states, attentional problems, personality styles, substance abuse, adolescent turmoil, and sociopathy all blur. In children, the diagnostic criteria are even murkier.

So what’s the problem? Or is there even a problem?

From the perspective of psychiatrists, we’ve lost the ability to communicate about our work with one another and we’ve lost our credibility with the public. The word “bipolar” means something different to everyone, and it’s not uncommon for people to say that psychiatrists over-diagnose, and misdiagnose, and “call everyone bipolar.” Patients will insist they don’t have bipolar disorder because they aren’t doing the things a bipolar neighbor does. Or they may embrace the diagnosis in a way that both defines and explains all of who they are. It’s not uncommon to hear patients say, “I’m bipolar” rather than “I have bipolar disorder” and to offer it up as an explanation.

Many people with these difficulties seem to either feel or behave better if they are treated with medications. It wouldn’t be such a big deal if the diagnosis were not attached to a mandate – or at least a strong recommendation – for lifetime treatment with medications, and if it didn’t bring to mind images of dangerousness, volatility, unpredictability, and perpetual dysfunction.

The truth is that people come to psychiatrists when they are in states of distress, and their ways of suffering don’t always fit neatly into one of the 297 diagnostic categories that DSM-IV-TR identifies. Insurers demand diagnoses (only certain ones, at that) and the unwritten rules of good medicine say it’s not okay to prescribe for a patient based on sheer desperation, yet that is what we sometimes do. We diagnose because diagnosis justifies treatment. Often our interventions work and our patients get better.

The diagnosis of bipolar disorder has come to sound ominous. And yet, the course it will follow is hard to predict. One person may have three or four discrete episodes in as many decades and function quite well otherwise; classic bipolar disorder where we know that mood stabilizers are likely to decrease the number and severity of episodes. Another patient may live in the chaotic upheaval of underachievement, lost jobs, and marital struggle, while a third patient may have symptoms so entrenched with substance abuse and violence that the issue of actual “mood” gets lost in the mix. Consider the young child who throws temper tantrums and is too volatile to remain in a classroom, but who does so much better once he starts medications, or the moody teenager who requires intervention but later outgrows his difficulties. Are we sure these patients all have the same illness? Are we sure they all need lifetime treatment?

Perhaps they are all variants of the same disease and certainly the expansion of the bipolar diagnosis has allowed more patients to access treatment and get help. But we don’t know that all patients captured by the expanded range of bipolar spectrum disorders need the “medicine for the rest of your life,” nor do we know their prognosis – we simply don’t yet have the data to reach these conclusions.

Until we do have answers from long-term studies, perhaps we need to reassess how we think about bipolar disorder, its treatment, and the picture we paint of it to our patients and the public.

Over on our original Shrink Rap blog, I asked our readers to write about how they define bipolar disorder and the comments that came in are more poignant and revealing than anything I could ever write. Please do read them by clicking here and feel free to join in the discussion.

My thanks to Dean McKinnon, M.D., author of Trouble in Mind, who served as my mood disorders expert for this article.

<[QM]>—Dinah Miller, M.D.

If you would like to comment on this article here, please register with Clinical Psychiatry News. If you are already registered, please log in to comment. You are also welcome to join the discussion on Shrink Rap at the post titled “What is Bipolar Disorder?”

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

Back in the day, manic depressive illness was a diagnosis reserved for those who suffered from discrete episodes of depressed or elevated mood states. We know that people who suffer from this illness, in this way, do better over time if they are treated with mood stabilizers, and patients are often told to remain on medications for life.

Over the past two decades, the diagnosis has expanded to include those patients with hypomanic episodes and chronic mood lability. The diagnosis has become a catch-all category for some patients with impulsivity, irritability, and behavioral dyscontrol, even in the absence of discrete syndromic episodes or prominent mood symptoms. We now talk about bipolar disorder in terms of type I, 2, (or even 3), rapid cycling, mixed states, and we refer to it as a “spectrum” disorder where the lines between anxiety states, attentional problems, personality styles, substance abuse, adolescent turmoil, and sociopathy all blur. In children, the diagnostic criteria are even murkier.

So what’s the problem? Or is there even a problem?

From the perspective of psychiatrists, we’ve lost the ability to communicate about our work with one another and we’ve lost our credibility with the public. The word “bipolar” means something different to everyone, and it’s not uncommon for people to say that psychiatrists over-diagnose, and misdiagnose, and “call everyone bipolar.” Patients will insist they don’t have bipolar disorder because they aren’t doing the things a bipolar neighbor does. Or they may embrace the diagnosis in a way that both defines and explains all of who they are. It’s not uncommon to hear patients say, “I’m bipolar” rather than “I have bipolar disorder” and to offer it up as an explanation.

Many people with these difficulties seem to either feel or behave better if they are treated with medications. It wouldn’t be such a big deal if the diagnosis were not attached to a mandate – or at least a strong recommendation – for lifetime treatment with medications, and if it didn’t bring to mind images of dangerousness, volatility, unpredictability, and perpetual dysfunction.

The truth is that people come to psychiatrists when they are in states of distress, and their ways of suffering don’t always fit neatly into one of the 297 diagnostic categories that DSM-IV-TR identifies. Insurers demand diagnoses (only certain ones, at that) and the unwritten rules of good medicine say it’s not okay to prescribe for a patient based on sheer desperation, yet that is what we sometimes do. We diagnose because diagnosis justifies treatment. Often our interventions work and our patients get better.

The diagnosis of bipolar disorder has come to sound ominous. And yet, the course it will follow is hard to predict. One person may have three or four discrete episodes in as many decades and function quite well otherwise; classic bipolar disorder where we know that mood stabilizers are likely to decrease the number and severity of episodes. Another patient may live in the chaotic upheaval of underachievement, lost jobs, and marital struggle, while a third patient may have symptoms so entrenched with substance abuse and violence that the issue of actual “mood” gets lost in the mix. Consider the young child who throws temper tantrums and is too volatile to remain in a classroom, but who does so much better once he starts medications, or the moody teenager who requires intervention but later outgrows his difficulties. Are we sure these patients all have the same illness? Are we sure they all need lifetime treatment?

Perhaps they are all variants of the same disease and certainly the expansion of the bipolar diagnosis has allowed more patients to access treatment and get help. But we don’t know that all patients captured by the expanded range of bipolar spectrum disorders need the “medicine for the rest of your life,” nor do we know their prognosis – we simply don’t yet have the data to reach these conclusions.

Until we do have answers from long-term studies, perhaps we need to reassess how we think about bipolar disorder, its treatment, and the picture we paint of it to our patients and the public.

Over on our original Shrink Rap blog, I asked our readers to write about how they define bipolar disorder and the comments that came in are more poignant and revealing than anything I could ever write. Please do read them by clicking here and feel free to join in the discussion.

My thanks to Dean McKinnon, M.D., author of Trouble in Mind, who served as my mood disorders expert for this article.

<[QM]>—Dinah Miller, M.D.

If you would like to comment on this article here, please register with Clinical Psychiatry News. If you are already registered, please log in to comment. You are also welcome to join the discussion on Shrink Rap at the post titled “What is Bipolar Disorder?”

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.