Lake Norman Psychiatry | Huntersville tag:www.lakenormanpsychiatrist.com,2010://1 2010-01-27T23:38:19Z Robin Stone, M.D. Huntersville, Lake Norman This is Dr. Stone’s blog site. If you are trying to reach her main web site for her outpatient practice, go to www.insight-psychiatry.com Movable Type 3.34 Not There Yet: Comparing the House & Senate Health Care Reform Bills tag:www.lakenormanpsychiatrist.com,2010://1.38 2010-01-07T23:34:27Z 2010-01-27T23:38:19Z On December 24, just as Santa was hitching his reindeer, the Senate passed a historical bill in support of health care reform. The gravity of the bill has been compared to the Social Security Act of 1935. Analysts point out,... http://www.insight-psychiatry.com Individual mandate: Both proposals require that Americans hold a minimum amount of health insurance, or face a financial penalty. The penalties differ slightly between the House and Senate proposals, but both exempt American Indians, people with religious objections, and people suffering financial hardship. Employer contribution: Both proposals require most employers to contribute to the cost of health insurance for at least some of their employees. The House version requires employers with a payroll of $500,000 or more to provide employee coverage, or pay a federal tax penalty. The Senate version does not stipulate that employers must supply insurance coverage, but companies with 50 or more full-time employees will face penalties if they do not. In the Senate version, employers who do not supply coverage will be required to provide vouchers to low- and middle-income earners who will be expected to buy their own coverage from an insurance exchange. Insurance exchange: The House proposal supports the creation of a national insurance exchange, whereas the Senate version allows the states to organize their own exchanges. Both proposals are open to individuals who do not qualify for insurance through their employer or a government program. The Senate version allows access to insurance exchanges for employers with less than 100 employees, while the House proposes a graduated approach—twenty-five or fewer employees in the first year of the program, 50 or fewer in the second year, and 100 or fewer in the third year. Public option: The House supports a public insurance option which would be operated on a non-profit basis by the government. This public insurer would negotiate directly with hospitals, doctors, and pharmaceutical companies. The Senate proposal does not include a public option—rather the government would enter into contracts with insurance companies to offer two national health plans, one of which would be operated as non-profit. Expand Medicaid: The House proposes to extend Medicaid coverage to everyone with incomes less than 150 percent of the poverty level ($33,075 for a family of four), while the Senate proposes to cover everyone with incomes less than 133 percent of the poverty level ($29,327 for a family of four). In both proposals the federal government would cover around 90 percent of the costs, with the states making up the balance. This works out favorably for the states because they currently contribute 43 percent to Medicaid costs on average. Insurance regulations: Both proposals prohibit insurers from denying coverage or charging higher premiums because of a person’s medical history or health condition. The House proposal goes further, however, by outlawing price fixing and bid rigging, and removing the current exemption of insurance companies from antitrust laws. The House is also more generous in limiting premiums for older people to no more than double that of younger people, while the Senate proposes a cap on premiums that are no more than three times higher for the elderly. The Senate also requires insurance companies to devote more of their income to medical claims by reducing their administrative overheads and spending at least 85 cents in every dollar on medical reimbursements. Illegal immigrants: The House proposal allows illegal immigrants to purchase coverage from insurance exchanges, while the Senate version does not. Abortion: In the House proposal, insurance plans can choose to cover abortion, but insurance exchange and public plans will exclude it. In the Senate proposal, health plans may choose to include abortion coverage, but states may elect to ban it. Moreover, people who do choose a plan that includes abortion will be required to pay the abortion component as a separate premium. Out-of-pocket expenses: Both proposals limit out-of-pocket spending—in the House version, $5000 for individuals and $10,000 for families; in the Senate version, $5950 for individuals and $11,900 for families. These limits would be reduced for people with income less than 400 percent of the poverty level—around $88,000 for a family of four. Paying for it: The House proposes to pay for reform via a 5.4 percent tax on very high income earners (families with a combined income of $1 million or more, and individuals earning more than $500,000), plus a 2.5 percent tax on medical devices sold in the United States, combined with savings in reduced aspects of Medicare. The Senate proposal is more complicated: a 40 percent tax on “Cadillac” insurance premiums, annual fees for pharmaceutical, medical device and insurance companies, savings against reduced aspects of Medicare, and a 10 percent tax on indoor tanning services. In both cases, the proposed legislation is intended to be fully implemented by around 2014. The next step, however, is to reconcile the differences between the bills passed by the House and the Senate. Republicans and lobby groups are also expected to make the passage difficult. Robin Stone, M.D. Insight Psychiatry 13123 Rosedale Hill Ave. Huntersville, NC 28078 704-948-3810 Further reading: Murray, S & Montgomery, L 2009 Senate passes health care bill, must now reconcile it with House, The Washington Post. Pear, R 2009 Senate Passes Health Care Overhaul on Party-Line Vote, The New York Times. ]]> Health Care Reform: Time to Stop Digging? tag:www.lakenormanpsychiatrist.com,2009://1.37 2009-12-18T00:29:17Z 2009-12-18T00:40:08Z Health care reform leapt back into the spotlight this week when independent Senator Joe Lieberman announced that he wouldn’t support any proposal that includes an expansion of Medicare or a public insurance option. Lieberman agrees with the Republican line that... http://www.insight-psychiatry.com Many physicians have been forced to stop accepting Medicare patients because of the program’s burdensome regulations and unstable payment system. Adding more patients to Medicare will force more physicians to make this difficult decision. Medicare payment rates have failed to keep pace with practice cost increases … Adding a new patient population to the program will only increase the cost shifting, raising premiums and health care costs for other Americans (2009). Lieberman’s stance comes after the Democrats introduced a bill that attempted to break the current senate impasse by proposing a Medicare buy-in option for people aged 55 and over (currently 65+) and not covered by employer-provided health insurance, as well as a network of government supervised private insurance plans. Lieberman’s opposition to the proposal deepens the political stalemate and threatens to dilute the reform. Meanwhile, the AMA’s position highlights the following conundrum: How will we, without increasing costs, extend coverage to more people (remember, nearly 46 million Americans are uninsured) while maintaining current health care practices? One of the answers might lie in eliminating unnecessary waste. The existing health system encourages doctors to order expensive procedures and tests through financial incentives, a culture of defensive medicine, as well as patient pressure on physicians to be overly-thorough. A 2006 study that looked at 4,600 preventative health checkups found that 43 percent of them resulted in unwarranted urine, X-ray or electrocardiogram tests on asymptomatic people (Lagorio 2006). If every American were to undergo these tests at an annual checkup, the costs would run into hundreds of millions of dollars (Pho 2008). There’s lots of talk about the cost of health reform, but what about the cost of not changing? According to the Urban Institute (2009), a nonpartisan research organization, if we make no major changes to the health system, the best case scenario is that by 2014—only five years from now—the number of uninsured Americans will reach 53 million. The worst case scenario is nearly 58 million. Insurance premiums, which have grown 131 percent in the last decade, will continue to grow. Poor affordability will necessitate an expansion of Medicare/Medicaid and further fragment health services. What do they say about holes? If you find yourself in one, stop digging? Robin Stone, M.D. Insight Psychiatry 13123 Rosedale Hill Ave. Huntersville, NC 28078 704-948-3810 Further reading: American Medical Association 2009 Health system reform bulletin, December 9. Holahan, J et al 2009 Health reform: the cost of failure, Urban Institute. Lagorio, C 2006 Needless medical tests costly, CBS News. Pho, K 2008 My take: just say no to unnecessary tests, KevinMD.com. ]]> Complementary &Alternative Medicine? Yes & No… tag:www.lakenormanpsychiatrist.com,2009://1.36 2009-12-01T16:12:15Z 2009-12-18T00:29:00Z A national study has revealed that 54 percent of people with self-reported severe depression have used complementary and alternative medicine (CAM) in the last 12 months. Two-thirds of them were also receiving conventional therapies (Saeed et al 2009). The October... http://www.insight-psychiatry.com Current Psychiatry features a meta-analysis that investigates the evidence base for the use of different CAM options in the treatment of severe depression: yoga, exercise, St John’s Wort, SAMe, fatty acids, L-tryptophan, and acupuncture. The benefits of exercise in the treatment of depression are well documented, and the meta-analysis confirmed this. Interestingly, however, the analysis also revealed that research into the health benefits of exercise in depression has tended to involve mainly young, physically sound patients, which means there’s little clinical evidence to support the extent of efficacy for older, less physically able patients. Still, the researchers recommend that the side effect profile of exercise is benign if a sensible exercise regime is accompanied by appropriate nutrition and hydration. While some studies have found that rigorous exercise (eg aerobics or resistance training) is more effective in treating depression than moderate exercise (eg walking), the meta-analysis revealed that yoga is just as effective as high intensity exercise in inducing symptom remission in severe depression. Polyunsaturated fatty acids—most commonly omega-3 and omega-6 oils derived from fish—are being praised lately for all sorts of health benefits for the joints, skin, and cardiovascular system. Research also indicates that they may be beneficial in treating depression, especially in combination with an SSRI (Saeed et al 2009). Some studies have also demonstrated that omega-3 is helpful in relieving symptoms of depression in patients suffering from Parkinson’s disease. Our bodies make S-adenosyl-L-methionine (SAMe) from methionine, an amino acid found in protein-rich foods. The molecule is a metabolite used in the bio-synthesis of norepinephrine, serotonin, and dopamine. Since the 1990s, it’s been available in the US as a dietary supplement and heralded in the popular press for its benefits in treating depression, arthritis, and liver problems. Most of the favorable studies for St John’s Wort have come from Europe, whereas American trials have not been able to establish a significant difference between the herb and placebo in treating major depression (Saeed et al 2007). While numerous studies have found that St John’s Wort can assist in inducing remission of depressive symptoms, research conducted by the National Center for Complementary & Alternative Medicine (NCCAM) at the National Institutes of Health (2007) did not find that St John’s Wort was any more effective than placebo. It also has some serious side effects which suggest that it shouldn’t be treated as an innocuous herbal remedy. It can also limit the effectiveness of other drugs including the birth control pill, antidepressants, cyclosporine, digoxin, medicines used to control HIV infection, anticancer medications, and anticoagulants as just a few examples (NCCAM 2007) L-tryptophan is an amino acid used in the biosynthesis of serotonin. It can be derived from foods or ingested as a dietary supplement. While a couple studies demonstrate benefits in combining L-tryptophan with conventional pharmacology in treating depression, the meta-analysis concluded that little clinical evidence exists to support its use. L-tryptophan is also implicated in causing eosinophilia-myalgia syndrome, which led the FDA to ban the sale of L- tryptophan in 1991. The FDA has since loosened the restrictions, although importation is still banned. While acupuncture may result in some symptom relief, the meta-analysis found that there’s no clinical evidence to suggest that it’s more effective than placebo. Research to date has been poorly designed and inconsistent. The side effect profile, however, seems to be rather benign. As always, if you intend to utilize a complementary medical treatment please advise your physician. Robin Stone, M.D. Insight Psychiatry 13123 Rosedale Hill Ave. Huntersville, NC 28078 704-948-3810 Further reading: Agency for Healthcare Research & Quality 2002 S-adenosyl-L-methionine for treatment of depression, osteoarthritis, and liver disease, US Deparment of Health & Human Services Evidence Report, no. 64. National Center for Complementary & Alternative Medicine (National Institutes of Health) | Get the Facts | St John’s Wort & Depression 2007. Saeed A., Bloch, R., et al 2009 CAM for your depressed patient: six recommended options, Current Psychiatry, vol. 8]]> Over The Counter, Under The Radar tag:www.lakenormanpsychiatrist.com,2009://1.35 2009-11-13T02:12:35Z 2009-11-13T02:28:06Z When I have a few spare minutes for surfing the web, I wouldn’t normally spend them looking at a website like Bodybuilding.com. But I was there, nonetheless, this afternoon. On the homepage I was greeted by a slideshow of before... http://www.insight-psychiatry.com 1994 Dietary Supplement Health and Education Act, dietary supplements are immune from FDA approval, and assumed to be safe. The act creates a backdoor through which manufacturers can slip badly labeled and contaminated supplement products onto the US market. Some of these contain undeclared and potentially dangerous active pharmaceutical ingredients such as amphetamines, diuretics, and steroids. To date, the FDA has uncovered around 140 contaminated products, and they suspect that around 50,000 unreported adverse events occur each year. While many of the contaminated products are manufactured overseas and sold on the internet, some of them have also made it onto retail shelves. Some manufacturers further attempt to avoid detection by replacing controlled active ingredients with chemical analogues that replicate the actions of the original compound. In addition to potential side effects, most of these analogues are yet to be clinically trialed for use in humans. The public generally doesn’t understand that these substances may be putting them at serious risk. Surveys have revealed that the majority of people believe that dietary supplements are regulated by the government. The misunderstanding is not limited to the general population. A study involving 300 internal medicine trainees, found that one-third of them believed that dietary supplements require FDA approval (Cohen 2009). I’ve certainly encountered issues in my practice where patients have misused dietary supplements—weight loss aides and bodybuilding products, in particular. In our society where there’s a pill to fix everything from erectile dysfunction to thinning eyelashes, it’s natural for people to self-medicate with an OTC remedy that promises to help them achieve their goals. The danger, however, is when people are led to believe that they’re taking natural, non-pharmaceutical products. These products don’t come with a prescription yet may contain prescription components, so the opportunity for misuse is rife. And given that dietary supplements fall outside of the FDA’s jurisdiction, there’s also little information about potential interactions between pharmaceutical products and dietary supplements. Writing in the New England Journal of Medicine, Pieter Cohen (2009) encourages physicians to be mindful that the ingredient list of a dietary supplement may not include all of the active components. He encourages doctors to report any suspected adverse events to the FDA (www.fda.gov/MedWatch/report.htm), even where the ingredient list suggests otherwise. Given that 114 million Americans (around half of all adults) consume dietary supplements, the public risk is significant and doctors are very likely, at some point in their practice, to encounter adverse events caused by a dietary supplement. It’s surprising that it’s taken the FDA this long to clamp down on the steroids that were being sold as ingredients in some of the dietary supplements available on Bodybuilding.com. During my cursory exploration of the website, I came across a chat forum titled Superdrol for Dummies in which a bodybuilder recommends a dosing regime for the steroid, along with Clomiphene, and Tamoxifen. At one point, he writes, “Clomid has worked excellently for me... It takes care of any testicular atrophy that may arise on [the] cycle” and “…make sure you give a full two month gap between cycles. After all you've got just one liver to use for a lifetime”. ‘Superdrol for Dummies’, indeed! Robin Stone, M.D. Insight Psychiatry 13123 Rosedale Hill Ave. Huntersville, NC 28078 704-948-3810 Further reading: Cohen, P 2009 American roulette—contaminated dietary supplements, New England Journal of Medicine, Oct 7. United States Food & Drug Administration (FDA) | Safety | Recalls | BODYBUILDING.COM Is Conducting a Voluntary Nationwide and International Recall of 65 Dietary Supplements That May Contain Steroids; November 3, 2009. ]]> Antidepressants implicated in male factor fertility tag:www.lakenormanpsychiatrist.com,2009://1.34 2009-11-04T17:27:22Z 2009-11-04T17:38:21Z A recent study (Tanrikut, et al) implicates SSRI’s, specifically paroxetine, with male fertility issues. The research builds on a litany of information about the effect of antidepressants on women during and after pregnancy, and begins to fill the void about... http://www.insight-psychiatry.com Robin Stone, M.D. Insight Psychiatry 13123 Rosedale Hill Ave. Huntersville, NC 28078 704-948-3810 Further reading: Wang, B 2009 Paroxetine may affect sperm quality, Reproductive Psychiatry Resource & Information Center of the Massachusetts General Hospital Center for Women’s Mental Health Tanrikut C, Schlegel PN. 2007. Antidepressant-associated changes in semen parameters. Urology 69(1):185.e5-7. Tanrikut C, Feldman AS, Altemus M, Paduch DA, Schlegel PN. 2009. Adverse effect of paroxetine on sperm Fertil Steril (in press).]]> Reforming the 'doctorless' health system tag:www.lakenormanpsychiatrist.com,2009://1.33 2009-10-16T23:57:01Z 2009-11-04T17:27:18Z It’s old news by now that the Senate Finance Committee has approved legislation that would attempt to reform our health care system. The major features of the revised Baucus bill would include mandatory health insurance for nearly all Americans, taxes... http://www.insight-psychiatry.com Robin Stone, M.D. Insight Psychiatry 13123 Rosedale Hill Ave. Huntersville, NC 28078 704-948-3810 Further reading: Eggen, D 2009 At $1.5 million a day, health sector lobbying far outpaces oil and gas, The Washington Post. Relman, AD 2009 Doctors as the key to health care reform, New England Journal of Medicine, 24 September, vol.361, no. 13. ]]> Reflections on Psychotherapy tag:www.lakenormanpsychiatrist.com,2009://1.32 2009-10-01T23:14:08Z 2009-10-16T18:18:37Z Health care reform highlights more than the changing nature of medicine—it highlights that social change is underpinned by ideologies that vie against each other in a competitive marketplace of ideas and values. I explored that topic in my last blog.... http://www.insight-psychiatry.com The investigators surveyed 14,108 visits to psychiatrists involving a psychiatric diagnosis. The percentage of visits with at least 30 minutes of psychotherapy decreased significantly over 10 years from 44 percent to 29 percent. For patients with private insurance, the decline was significant (from 50 percent to 25 percent), but not for those in publicly funded programs, where the initial percentage was low (Medicare, from 32 percent to 21 percent; Medicaid, from 22 percent to 13 percent). The percentage was highest among self-paying patients and did not change significantly (from 55 percent to 59 percent). In HMOs, the percentage of visits with psychotherapy decreased significantly to a remarkable degree (from 23 percent to 5 percent) (Dubovsky 2008). In short, psychotherapy is being eroded from psychiatric practice and, upon reflection, there are a number of environmental causes. The most significant factor is an economic one. Psychiatrists who work within managed care programs administered by insurance companies are discouraged from combining psychotherapy with pharmacotherapy. They’re under pressure to see a large number of patients and work within a system that rewards short consultations. The same study revealed that ‘third-party reimbursement to psychiatrists is 41 percent less for one 45-minute psychotherapy session than for three 15-minute "med checks."’ (Dubovsky 2008). At the same time, there’s been a paradigm shift in psychiatry that focuses on mental illness as a physiological disease—a biological imbalance that can be chemically corrected. As a consequence, there’s stronger emphasis on drugs in psychiatry—a trend which finds favor with pharmaceutical companies, cost-conscious insurers, and patients looking for fast relief. Anti-depressants are now the most commonly prescribed drug in the US. Indeed, psychotropic drugs have revolutionized psychiatry by strengthening the biological component of the biopsychosocial model—but I’ve also seen, over and over, that pharmacotherapy is rarely a complete solution. People are complicated—more complicated than chemistry alone can account for. They ultimately seek to be understood and to understand themselves, not just to be promised that their neurotransmitters will be set right with a pill. It’s the relationship that heals, and the correct formulation of diagnosis and treatment is powerful in, and of, itself. Think of someone who’s never understood why they think, behave, or feel the way they do, and has suffered greatly most of their life. For example, they may have experienced emotional problems, anxiety, interpersonal difficulties, or failed career aspirations. Now interject another person who’s trained to illuminate reasons—taking into account the biological, social, psychological aspects of their circumstances—in a safe, non-judgmental arena, and at the right point in a patient’s life. The key to improved mental health lies in not only alleviating a patient’s symptoms, but in helping them to understand and address the underlying causes of those symptoms. When a patient improves through insight and understanding, they gain a much better sense of control over their disorder. The result is that they experience a more positive prognosis, which might be more aptly described as a better life. The pendulum is swinging back as mounting clinical research demonstrates that psychotherapy is more effective than drugs alone in treating many mental disorders. (Refer to the American Psychiatric Foundation for further information about clinical findings). The positive effects of psychotherapy can be measured not only by symptom relief, relapse reduction, and patient wellbeing, but by physiological changes in the brain. They key here is that the growing proof for psychotherapy not only appeals to the medical and scientific community, but that it also piques the interest of penny-wise insurance companies! Robin Stone, M.D. Insight Psychiatry 13123 Rosedale Hill Ave. Huntersville, NC 28078 704-948-3810 References & further reading: American Psychiatric Foundation 2008 Psychotherapy basics, Mental HealthWorks. Mojtabai, R & Olfson, M 2008 National trends in psychotherapy by office-based psychiatrists, Archives of General Psychiatry, vol. 65, no. 8. Dubovsky, S 2008 Psychiatric practice: a march from the brainless to the mindless?, Journal Watch Psychiatry, September 15. ]]> Ideology and the Heath Care Debate tag:www.lakenormanpsychiatrist.com,2009://1.30 2009-09-11T03:02:29Z 2009-09-13T02:08:55Z In October 2009, Physicians Practice will publish the findings of their annual survey. Nearly 1600 physicians were asked this year about what health care reforms they’d like to see. Among the top ten were ‘get the government out of medicine... http://www.insight-psychiatry.com Physicians Practice will publish the findings of their annual survey. Nearly 1600 physicians were asked this year about what health care reforms they’d like to see. Among the top ten were ‘get the government out of medicine entirely’, ‘institute a single-payer system that has universal coverage’, and ‘cap insurance and pharmaceutical company profits’. The results highlight the ideological divide between those segments that’d prefer to see more government involvement in our health care system, and those that’d prefer to see less—much less! The ideological divide was no less evident in Washington on Wednesday night when President Obama addressed congress to explain some of the details of his plan for health care reform. The President’s reforms propose to offer more choice, lower costs, and improved security for people who already have health insurance. Under the proposal, insurance companies would not be allowed to drop or dilute coverage. For the uninsured, the new plan proposes affordable coverage for individuals and small business owners. Among other changes, it’d be unlawful for insurance companies to deny an applicant coverage on the basis of a pre-existing condition. Other proposed reforms include pilot studies for changes to medical malpractice laws. The President made it clear that, while alternative proposals were welcome, he would not lie down easily on a public insurance option, nor his concept of an insurance exchange. In his words, a public insurance option would provide better choice and competition for consumers. Dr Charles Boustany replied on behalf of the Republicans. He told the press that his party opposes a government-operated insurance agency, and argued that competition in the insurance market could be improved by allowing families and small businesses to purchase their insurance across state lines. One political commentator described the presidential address as ‘vintage Obama’, highlighting what he saw as a veiled contradiction: ‘Complete command of the issue, excellent cadence and pace. The reach out, as expected, to the GOP to join him half way, while standing firm on his beliefs and denouncing what he saw as the "politics" of division’(Rudin 2009). Another agreed that the President failed to exhibit the attitude of compromise he was demanding. William McKenzie of The Dallas Morning News wrote:
[Under Obama’s plan] there's no guarantee you can keep your health plan. If your company stops offering coverage and you end up on a public plan, you could lose your doctor. Look at Medicare. Washington has been tightening up Medicare payments to doctors, so fewer providers are picking up seniors. The same phenomenon could happen under a public plan. If you end up on it, and your doctor chooses not to participate, you're out of luck. The president wants a public option so consumers can have more insurance choices. Well, they could get more options if he supported letting insurers and consumers connect across state lines. That way, we all could get plenty of choices and wouldn't have to worry about the headaches of creating a federal plan.
All this political crossfire overshadows the facts. The US has the most expensive health care system in the world—around 1.5 times more expensive per capita than the average of other developed nations. For every six dollars an American earns, they spend more than one dollar on health care (Gawande 2009). You’d think, therefore, that our nation would be exceptionally healthy. Instead, we’re ranked 42nd in the world for average life expectancy—just above Mexico—and we have the dreadful honor of being the fattest country on the planet (Ohlemacher 2007). Research reveals that 41 percent of working age adults in the US have a medical debt, or have a problem paying medical bills (Gardner 2008). A study published in the American Journal of Medicine found that nearly two-thirds of personal bankruptcies filed in the US in 2007 were caused by illness and medical expenses. More concerning, most of these people had insurance at the start of their illness, were middle class, university-educated, and owned a home (Healy 2009). Meanwhile, insurance companies and their executives are rewarded for the relentless pursuit of profits. The Democrats and GOP have agreed on a middle ground when it comes to expanding insurance access for people with pre-existing conditions, and providing health care assistance for very low income earners. But the coming months will further tell if our representatives in Washington are able to conceive of the world in shades of gray by building a bridge of compromise between their ideologies—or if they are only capable of confusing and polarizing the constituency. The danger of not compromising on ideology is that we will continue to compromise our health. Robin Stone, M.D. Insight Psychiatry 13123 Rosedale Hill Ave. Huntersville, NC 28078 704-948-3810 References & further reading: Beckel, A & Michael, S 2009 Ten health reforms docs want, Physicians Practice. Gardner, A 2008 Medical debt sending many over financial brink, US News & World Report. Gawande, A 2009 The cost conundrum: what a Texas town can teach us about health care, The New Yorker. Healy, M 2009 Medical bills led to two-thirds of bankruptcies in 2007, study finds, Los Angeles Times. McKenzie, W 2009 Obama's health care speech got it right and wrong, National Public Radio. Rudin, K 2009 The President spoke. What did people hear? What will congress do?, National Public Radio. ]]> When Healers Need Healing tag:www.lakenormanpsychiatrist.com,2009://1.29 2009-09-06T21:40:11Z 2009-10-16T18:19:14Z In the last 30 years, ‘burnout’ has turned from a vernacular idiom into a prevalent psychosocial syndrome—one that’s particularly relevant in current times as the economic recession impacts on lifestyles. Surveys reveal that job cuts and the threat of redundancy... http://www.insight-psychiatry.com Robin Stone, M.D. Insight Psychiatry 13123 Rosedale Hill Ave. Huntersville, NC 28078 704-948-3810 References & further reading: Gundersen, L. 2001 ‘Physician burnout’, Annals of Internal Medicine, vol. 135, no.2, pp. 145-148. Spickard, A., Gabbe S., Christensen, J. 2002 , ‘Mid-career burnout in generalist and specialist physicians’, Journal of the American Medical Association, vol. 288. no. 12. ]]> Depression or ‘soft’ bipolar disorder? tag:www.lakenormanpsychiatrist.com,2009://1.28 2009-08-21T02:40:28Z 2009-10-16T18:19:33Z Depression is among the top three causes of death and disability in the US (Michaud et al 2006). Consequently, primary care providers spend an increasing amount of time diagnosing and treating mental health disorders. Most patients seeking help for mental... http://www.insight-psychiatry.com The Lancet reveals the difficulties primary care doctors encounter in properly diagnosing depression (Kelly 2009). This is not a criticism of primary care providers. Rather, it highlights that mental health disorders can present with many different symptoms and phases. It is concerning, however, that studies reveal that up to 50 percent of patients diagnosed with recurrent depression have features of mild hypomania, considered the ‘soft’ end of the bipolar spectrum. Clinical research suggests that these patients might be more effectively treated within the framework of bipolar II disorder (Smith 2009). Hypomania can be difficult to identify because it’s less pronounced than mania. Patients can be unaware of the cycling nature of their mood, and only seek treatment when they’re feeling depressed. As a consequence, patients can be misdiagnosed with depression for years (sometimes decades) before receiving proper diagnosis and treatment. Again, this is not a criticism of primary care providers—bipolar disorder is a complex condition that tests every clinician’s diagnostic acumen and treatment skills. This is especially so for ‘soft’ bipolarity. What are the consequences of misdiagnosing bipolar II disorder as major depressive disorder? In addition to delayed recovery, the primary concern is that antidepressant medications may carry a risk of worsening some patients’ symptoms. ‘Antidepressant monotherapy for bipolar depression—at least for some patients—can cause more frequent mood episodes, mood destabilization, and possibly an increase in suicidal behaviors’ (Smith 2009). Patients who are not feeling improvements within a few of weeks of beginning antidepressant therapy should seek specialty care. Diagnosis of bipolar II disorder demands detailed psychiatric assessment. Clinician’s are also encouraged to seek a corroborative history from a close relative of the patient to help identify if hypomania is present. Most bipolar II patients will require a multi-modal therapy approach, including psychotherapy. I welcome inquiries from mental health professionals and members of the public. Robin Stone, M.D. Insight Psychiatry 13123 Rosedale Hill Ave. Huntersville, NC 28078 704-948-3810 References & further reading: Smith, DJ 2009 ‘Soft bipolarity: how to recognize and treat bipolar II disorder’, Current Psychiatry, vol. 8, no. 7. Kelly, J 2009 ‘Depression Often Misdiagnosed in Primary Care’, Medscape. Michaud, CM et al 2006 ‘The burden of disease and injury in the United States 1996’, Population Health Metrics, vol. 4, no. 11. ]]> Synthetic Oxytocin, Cocaine of the Future? tag:www.lakenormanpsychiatrist.com,2009://1.27 2009-05-22T23:10:52Z 2009-06-02T17:19:10Z When reading an article in nature magazine about the potential uses of oxytocin as an anti-anxiety hormone, I suddenly thought of a world like that in Aldous Huxley’s “The Wanting Seed.” Everyone has days when a soma holiday looks appealing... http://www.insight-psychiatry.com soma holiday looks appealing I’m sure. Oxytocin is a hormone naturally produced by the brain that is presumed to aide attachment and social recognition. Researchers have shown that release peaks during orgasm, and higher levels are found in the bloodstream of those who are in the throes of romance. Perhaps more commonly understood as the hormone responsible for milk letdown in breastfeeding, and enhanced uterine contractions during labor, researchers think it may be helpful in attenuating fear responses in social situations. If true, it may have implications as a novel treatment for social anxiety disorder or social deficits seen in other psychiatric conditions. Researchers including Thomas Insel, MD Director of National Institute of Mental Health, and European counterparts at Cambridge report that data is due out in July of this year regarding the likelihood of an analog of oxytocin becoming a drug trial candidate. They admit that synthetic hormones have limited bioavailability due to difficulties in crossing the blood-brain barrier (and that intranasal preparations have shown only short-term effects). A biotechnology firm based out of Washington—MDRNA, Inc. is considering a project to develop a longer acting intranasal formulation. References: December 2005, Journal of Neuroscience, author Thomas Baumgartner PhD August 2008, Biological Psychiatry, author Gregor Domes PhD Article in Psychiatric News, November 21, 2008 Robin Stone, M.D. Insight Psychiatry 13123 Rosedale Hill Ave. Huntersville, NC 28078 704-948-3810 ]]> Stress Hormone May Identify Risk For Postpartum Depression tag:www.lakenormanpsychiatrist.com,2009://1.26 2009-04-03T15:03:19Z 2009-06-02T17:09:57Z Risk factors for postpartum depression include depression before or during pregnancy, a history of premenstrual syndrome as well as a history of mood changes with oral contraceptive use. Social risks include inadequate family support, or personality factors such as trait... http://www.insight-psychiatry.com Archives of General Psychiatry. Robin Stone, M.D. Insight Psychiatry 13123 Rosedale Hill Ave. Huntersville, NC 28078 704-948-3810 ]]> Too bad United, maybe it’s Karma tag:www.lakenormanpsychiatrist.com,2009://1.25 2009-02-08T19:56:50Z 2009-02-11T22:58:00Z United Healthcare recently settled a 350 million dollar suit, agreeing they had been systematically low-balling “usual and customary rates” and in the process shortchanging both patients and physicians. The agreement with NY state attorney Andrew Cuomo requires them to scrap... http://www.insight-psychiatry.com American Medical News, February 2, 2009 Insight Psychiatry www.insight-psychiatry.com 13123 Rosedale Hill Ave. Huntersville, NC 28078 704-948-3810 ]]> Obama’s Stimulus Plan Falls Short on Healthcare tag:www.lakenormanpsychiatrist.com,2009://1.24 2009-02-05T17:52:23Z 2009-02-11T22:55:19Z Joseph Heyman, MD Chair of the AMA board of Trustees recently released a commentary regarding healthcare reform under the new administration. The stimulus bill provides for expansion of medicaid, aid to those recently unemployed (expanded gap insurance or COBRA assistance)... http://www.insight-psychiatry.com “Physicians need one voice to fight for payment reform” Robin Stone, M.D. www.insight-psychiatry.com 13123 Rosedale Hill Ave. Huntersville, NC 28078 704-948-3810 ]]> Paging Marcus Welby… tag:www.lakenormanpsychiatrist.com,2008://1.23 2008-11-30T20:28:57Z 2009-12-18T00:02:12Z If you could get your doctor to change one thing, what would it be? A reasonable question given today’s healthcare environment. Apparently one that sparked quite a few postings in WSJ’s forum section. It appears some physicians feel more satisfied... http://www.insight-psychiatry.com paid for by the Physicians’ Foundation (an organization founded with monies garnered after a class action lawsuit physicians won against third party payors). Second, the survey was performed by Merritt, Hawkins and Associates (a healthcare consulting and physician recruiting firm). Third, and most importantly, the survey was mailed to 320,000 physicians (only 11,950 responded). Now it stands to reason that the people most likely to post on physician discussion boards, or return surveys such as this are dissatisfied e.g.: an impetus for taking time out to respond (If knowledge serves this error is referred to as responder bias—a huge confounder in most survey-based research) Wouldn’t it be in the interest of Merritt Hawkins to support the notion of a physician shortage? After all, they are in the business of prostituting physicians (oops I mean recruiting) for hospitals and other healthcare entities. Who is the true benefactor here? All of the percentages listed are extrapolated from 12,000 respondents (less than 3.8% of the total number surveyed…and an even smaller percentage of physicians nationwide) How is this representative of what doctors really think about their career decision, or job satisfaction? To those who would complain about being a physician, get out…your bitching and moaning about the healthcare crisis is not part of the solution. If you don’t like working for the insurance company, or hospital administration, there are plenty of other opportunities to help patients in non-traditional practice models. If you build it…they will come. www.insight-psychiatry.com References: CNN Video - Family doctor shortage The Physicians' Foundation - Survey Bostom.com - The crisis of primary care physicians www.merritthawkins.com WSJ - Doctors Feel Gloomy, Financially Strapped Robin Stone, M.D. Insight Psychiatry 13123 Rosedale Hill Ave. Huntersville, NC 28078 704-948-3810 ]]>