Tag: mental health services

Has the U.S. Become an Anti-Scientific Nation?

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On Sunday night our book club met to discuss Richard Dawkins’ Greatest Show on Earth. While I had a bit of difficulty with his style of writing, the data Dawkins presents in explication and support of evolution is exhaustive. Even with such overwhelming evidence, he reports that a full 44% of Americans surveyed in 2008 do not believe that evolution occurred. They deny the fact that all life forms on earth, including humans, descended from some common ancestor; Dawkins calls them 44% ‘history-deniers.’

On Saturday night, we finally saw Avatar. Among the themes explored in this movie was the strong prejudice that exists today against science and scientists. Technology…the practical outcome of scientific endeavor… is valued. Everyone on that space settlement was a technician of some sort. But the science that got them there and the science allowing the use of real avatars was denigrated by the majority.

A few weeks ago, I wrote about behavioral health professionals use of evidence based treatments. Behavioral health professionals and psychologists in particular are generally well-trained scientists, having a good understanding of the scientific method plus training in critical judgement of research. One goal of this education is to choose the soundest methods of providing care. And yet, large numbers of psychologists indicate that they do what they “believe” is best for their clients rather than what scientific research indicates is likely to provide the most effective course of treatment.

Numerous writers and commentators have bemoaned the state of science education in this country. At one time the U.S. was generally regarded to be the place to get the best education in science. Students from across the world came to the U.S. to study. Some stayed, some returned to their home lands to teach others. A 2007 article in the Christian Science Monitor ranked U.S. high school students 29th in the world in science literacy. While others would argue this figure, the common perception is that we have slipped as a nation in our interest in, and understanding of, science.

Simultaneously, we have become technology addicts. I would venture to say that many young people who are technology drones have never really thought about the science that went into creating the devices they cannot live without. Nor do they care that they do not know about the science. Just make sure that they continue to have access to their toys and to the technological infrastructure that supports them.

I believe this trajectory puts us as a nation in a very vulnerable position. Technological innovations are only one aspect of scientific endeavors. The knowledge gained from pure science is one of the things that keeps me most in touch with my creativity and my humanity. Take a listen sometime to Science Friday, an NPR program and podcast that weekly explores a whole variety of science topics and themes. It is impossible for me to listen to more than two or three of these shows without coming away with a book I want to read. I referenced one of these shows in my article on Evidence Based Treatment.

Those who provide behavioral health care services are unlikely to find the bulk of their work taken over by technology. There will be technologies that facilitate treatment and technologies that become treatments, but the bulk of human services will still be provided by humans. Assuring that we are good scientists, or at least can judge when a study is good science, is a worthwhile goal for behavioral health providers of every stripe.

How do you rate our science literacy? Are you interested in or bored to tears by science? Do you see science as relevant to your life…as a human being or as a provider of services?

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Integrating Behavioral Health and Primary Care

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The September 29, 2009 edition of NJAMHA Newswire reports on a trend appearing strongly in New Jersey and in many other states: attempts to provide primary care treatment at the behavioral health setting or alternatively, to integrate behavioral health treatment into the primary care setting. In fact, the National Council, the major membership organization of community behavioral health care providers, has introduced an online Resource Center for primary care and behavioral health collaboration on their web site. This center comes out of six years of work in this arena.

FierceHealthcare, a daily newsletter for health care executives, reported on this trend in its September 30, 2009 edition. The article mentions the research literature that documents the tendency of primary-care physicians to miss the signs of common mental health issues like depression. Overlooking the mental health issues can often complicate both behavioral health and physical health treatment. A diabetic who experiences some debilitating mental health issue may not be able to comply with their required diet and self-care, just as a pregnant woman taking lithium to manage her bipolar disorder faces consequences for her child from her medication. The behavioral health and physical issues are inextricably intertwined.

Behavioral Healthcare online edition of October 1, 2009 reported a SAMHSA-funded study that indicated that general practitioners, not psychiatrists, are the most frequent prescribers of psychotropic medications. This includes pediatricians among the GP category since they usually are the primary care physicians for children.

The FierceHealthcare article identifies the financial and health benefits of the integration of mental health screening and prescribing into primary health care settings. Making sure that mental illness is not overlooked is one way of assuring that patients get the most effective treatment for all of their illnesses.

Since mental health treatment has usually been considered specialist-level care, there is concern among behavioral health providers that such screening and treatment by GPs is not the appropriate care in the right setting. Given how busy primary care providers are, it is highly likely that medications will be prescribed without psychotherapy or other appropriate behavioral interventions.

Health care reform is focused on saving money and providing effective care as efficiently as possible. Some would argue that the primary care provider’s intervention in behavioral health issues is the appropriate, cost-effective way to assure proper diagnosis and treatment. Most mental health providers I know would disagree, perhaps arguing that screening and referral to specialists is the appropriate and most effective way to provide care.

What are your thoughts on this issue? Do you see the possible integration of behavioral health care and primary care as positive for you and your clients? How is this likely to impact the way you currently provide services? What about those of you who already work in primary care settings; is this the ideal way to provide care to all patients, to complicated patients, or to no one at all?

Please let us know your thoughts on this issue. Just click on the title of the article and enter your comments in the box at the bottom of the page.

Healthcare Reform: Where does mental health fit in?

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I was all set to write an article on various health disorders and their cost. Then I got frustrated. You see, I started reading the original articles upon which the news/opinion articles I was using as reference were based. I found very rapidly that the figures being used in the articles were comparing different things…some of the totals included reporting by consumers of care; some of the totals included services under multiple diagnoses; adding the totals together summed to much more than we spend on all health care all told. I wonder  how much of this misuse of data is occurring during our ongoing national discussion of health care reform. Apples and oranges are not the same and mixing data can result in sloppy conclusions.

On September 10, 2009, the New York Times published an Op-Ed piece by Michael Pollan in which he discusses the costs of health care in the U.S. Big Food vs. Big Insurance discusses the report of the Centers for Disease Control that chronic illnesses account for 70% of all U.S. deaths. The medical bills of those with chronic diseases result in 75% of the health care spending in the U.S. Pollan argues that some of those chronic diseases…obesity, diabetes, cardiovascular disease…are at least partially the result of America’s terrible diet and overeating. Just helping U.S. residents eat better could result in a dramatic reduction in the costs of health care.

Pollan’s position received some confirmation from a podcast of Science Friday on August 28, 2009. How Cooking Made Us Human focused on the hypothesis that humans evolved effectively and developed larger brains because we started cooking our food. Cooking begins breaking food down before it is eaten, so it is easier to digest. Raw food is harder for the body to digest, so one does not get as much nutritional benefit from the food eaten. The result for human evolution was that we were able to take better advantage of the food we ate by cooking it.

The corollary of this hyothesis is that highly processed foods are a big contributor to obesity because they are too easy to digest. The more processed the food, the easier it is for our bodies to use the caloric content of the food. The result is that those whose diets consist largely of processed foods are also heavier. Raw foods are likely good for some who want to lose weight because the body has to work harder to digest them and does not get all the caloric benefit from the food. One can eat more, feel more full, but consume fewer calories.

Pollan’s point that a change in one aspect of our lives could have huge impact on health care spending got me to wondering…is there a mental health issue that is analogous to food/eating related disorders like obesity, diabetes and heart disease?

According to Open Minds On-Line News for September 14, 2009, mental disorders jumped from fifth place among health expenditures in 1996 to third place in 2006 increasing from $35.2 billion to $57.5 billion. The number of people who sought treatment for mental conditions went from 19.3 billion in 1996 to 36.2 billion people in 2006. While the dollars expended per person for behavioral health care are many fewer than for heart conditions ($1591 vs. $3964), perhaps there is a way for behavioral health providers to dramatically reduce costs of care by addressing a single problem.

According to the U.S. Surgeon General, approximately 20% of the U.S. population experience some sort of mental health disorder in any given year. The best estimate is that 16.4% of the population experience some sort of anxiety disorder ranging from Simple Phobia to Post Traumatic Stress Disorder. A full 82% of those who experience a behavioral health disorder suffer from some sort of anxiety disorder.

Is it possible that education on stress reduction, prevention programs aimed at inoculating the U.S. population against anxiety and early treatment of anxiety disorders might decrease the cost of treating the disorders that do emerge? I have heard public health specialists argue that public education and prevention are the only way we will ever get our health care spending under control. I also have read that there is not yet compelling data to demonstrate that preventive care reduces costs at all.  Perhaps we should just focus our attention on the behavioral aspects of the chronic physical diseases? Or maybe behavioral health providers can work in both arenas and assist in dramatically diminishing the costs of health care across the board.

What do you think about this issue? Where should psychologists, psychiatrists, social workers, mental health counselors, community mental health centers and community behavioral organizations focus their energy? Where will our energies be most effectively spent?

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U.S. Healthcare…Privilege, Poverty and Pain

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This is my second day back in the office after vacation. Yesterday and this morning were filled with catching up. That will take most of the rest of the week to complete. I decided to share an experience and some reflections before I get too removed from them.

While on vacation, my back went out. I have had chronic back issues since I was a young woman…maybe even since I was a child. In January 2007, I fell from my bicycle and separated my shoulder. Since October 2007, I have regularly visited a chiropractor to manage the neck pain that has become a focus since that fall. My neck and back have become chronic problems with intensity of pain varying depending upon multiple factors.

Vacation was a bicycling getaway in the Florida panhandle. The cottage we stayed at in Apalachicola had a bed that did not agree with my back. After two nights of wrong mattress and two days of riding, my lower back went into major spasm. I spent the third day of vacation searching for a massage therapist and traveling 100 miles to purchase a mattress topper to ease the pain. Everyone with whom we dealt was extremely kind and concerned, even when they were not able to help.

I did manage to relieve the discomfort somewhat and rode for three more days after we moved on to Monticello. Some correction to my bike position and change in pedaling technique also helped. You will notice that I did not try to see a physician and I did not go to an emergency room. Dealing with out-of-network services for a chronic rather than emergent condition felt too costly to justify. Fortunately, I found a massage therapist and could afford to pay her.

On our final day, we visited Thomasville, GA. As we drove into town, we passed a demonstration opposing health care reform. Signs indicated that “they” are going to increase our taxes to pay for someone else’s healthcare, and  “we” cannot afford to pay for the poor to have insurance. The participants were overwhelmingly white skinned, well-dressed individuals.

Today I managed to get to my own chiropractor and massage therapist. My insurance only pays the chiropractor $15 per visit; they do not cover massage therapy at all. Because these services keep me functioning, I choose to pay for them and am fortunate to be able to do so. But during this summer when Congress is working hard to come up with a plan to reform our healthcare system so more people can afford to receive care, I find myself wondering how we will succeed.

1. From amidst my pain, my thinking about how to resolve my discomfort was minimal and ineffectual. Soaking in the tub did not take care of the problem. Over the counter medications did not relieve the pain. Without my husband to find resources for me, I might still be in that tub. I think about the emotionally ill individual who has no one to advocate for them…mired in their pain and confusion without treatment.

2. Even with good, costly health insurance, the community in which I was located did not have resources for which my insurance would pay. If I were not privileged and educated and benefiting from adequate income, I would have been unable to pay for the resources we did locate. There are no local mental health services at all. I think of those who live in small town America and cannot travel to the resources of larger communities, as well as those who live in cities who cannot afford to access those resources.

3. I know very few health care providers or training programs or modern treatment procedures that were not assisted by government funds. Health research and hospitals and medical school and even graduate school in psychology cost too much for most of us to pay without government grants or loans. Even those of us who can afford to pay are dramatically benefited by government funding.

4. We are a kind and concerned people.

5. We are selfish and protective of our money, our privilege and our position.

6. There are no easy solutions to healthcare reform. It is going to cost all of us. The only question is how much it will cost and how we will pay for it, and whether the mechanisms are different from how we pay now. It is unconscionable that access to basic healthcare is not guaranteed to everyone who lives in the U.S.

This is all my opinion…for what it is worth. And what do you think? Please make your comments by clicking on the title of this article and entering your thoughts in the box at the bottom of the page.

Measuring the Quality of Mental Health Treatment

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This week’s entry is a guest article by Dr. Vince Bellwoar, a psychologist user of our software whose practice is located in Pennsylvania. Vince posted a question on our SOS user group about how other users measure quality of care. This spurred significant discussion on that group. I am hopeful that it will also stir up some discussion here. -Kathy

 

Our practice has always aspired to provide excellent quality. What business hasn’t? This article is meant to stimulate discussion as how to address and improve the quality of clinical practice.

We emphasize two points in hiring: 5 years of solid clinical work and very good people skills. If we can’t imagine a range of patients connecting with you, we are not hiring you. The next step is to monitor how well the therapist holds patients. Billing software with decent reporting capabilities can be an invaluable resource here.

Patients who stay in treatment tend to get better, and as they improve, they’ll refer others. In contrast, therapists who lose 40% of new referrals by the 3rd session usually are doing so out of errors of omission or commission. Our billing software allows us to mine the data that tells us what percent of new referrals continue with each therapist after the 3rd session. Granted, this is a blunt assessment tool; and so we have searched for other means of assessment.

After my car is in the shop for service, I get a call asking, “How did we do?” We tried something similar with a patient satisfaction survey sent to patients whose last treatment session was more than six weeks ago. (This assumes that a six week break from treatment meant the client was done with treatment for now). Unfortunately, the return rate was only 10% even though we provided stamped return envelopes or used email. Our next attempt will be to put the survey in waiting rooms with large signs encouraging completion. We want to keep the surveys out of the treatment session as many believe this could change the nature of the treatment session.

There are numerous satisfaction surveys out there. I find the ones constructed by insurance companies are particularly bad, not to mention self-serving. They see success as getting patients out of treatment ASAP. We constructed our own survey, yet it doesn’t seem to get at the heart of the matter: what was specifically helpful or not helpful in the therapy session. What did the therapist do (commit) or not do (omit) that made the treatment better or worse?

Our next survey version will pose these open-ended questions. I hope that this will generate the type of quantitative and hearty data that can complement the qualitative data from our billing software—and ultimately be beneficial to therapists.

Our goal is to identify what happens in a therapy session that makes a therapist “good”. Then we can give the therapist concrete, usable feedback that encourages improvement. We want people who are interested in this type of feedback, whether they are a therapist, secretary, psychiatrist, and, yes, even the owner!

I welcome your feedback.

Vince Bellwoar, Ph.D.
http://www.springfieldpsychological.com