TXPsychiatrist FebMar07 2/20/07 6:32 PM Page 1

FEBRUARY / MARCH 2007 Psychiatrist Seeking Equal Benefits for Psychiatric Illnesses

“Parity” has been a rallying cry for psychia- Business Group on Health following a study most mental illnesses there is a range of mental healthcare spending in the trists, advocates and family members who performed by the National Committee on well-tolerated and effective treatments. United States (including expenditures have been attempting to pass legislation that Employer-Sponsored Behavioral Health Current research suggests that the most from private insurance, Medicare, will require insurance companies to provide Services. The Committee consisted of 25 effective method of treatment is multi- Medicaid, etc); by 2001, psychotropic benefits for psychiatric illnesses that are the benefits and healthcare experts including modal and combines pharmacological drug spending was responsible for 21.0% management with psychosocial inter- of total mental health spending. In 2001, same as provided for “physical” illnesses. academic researchers, disability manage- ventions such as psychotherapy. private employers spent approximately These attempts have been successful to a ment professionals, Employee Assistance 5. A significant proportion of individuals 17% of their total behavioral health limited degree in Texas with passage of parity Program (EAP) professionals, healthcare with behavioral health problems are expenditures on prescription medica- legislation in 1991 and 1997. However, the benefits specialists, representatives from treated exclusively in the general med- tions. legislation passed in Texas still has limita- managed care and managed behavioral ical setting, which has become the “de- 8. While employers have focused their tions on benefits and illnesses covered. health organizations, pharmacology experts facto mental healthcare system.” Among attention on the management of high Efforts will be made in the current legisla- and medical directors and benefits managers patients diagnosed with a mental illness, cost chronic medical conditions (e.g., tion session to expand insurance benefits to from Business Group member companies. 42% of those with clinical depression and heart disease and type 2 diabetes), such cover all psychiatric disorders at the same The following is a summary of key 47% of those with generalized anxiety management efforts have not fully levels other medical illnesses are covered. findings and recommendations of the disorder (GAD) were first diagnosed by a addressed the significant additional Two bills have been filed to date that will Committee as documented in the Guide: primary care physician. Approximately burden of co-morbid mental illness. require health plans to provide coverage for 22.8% of individuals treated for a mental Access to specialty behavioral health- the diagnosis and treatment of mental disor- Key Findings illness or substance abuse disorder, and care services is critical to delivering ders under the same terms and conditions as 1. Mental illness and substance abuse half (51.6%) of patients treated for effective disease management services depression, are treated by a general med- for chronic medical problems. coverage provided for the diagnosis and disorders are serious, common, and expensive health problems. In 2001 ical provider such as a primary care Therefore, limitations on behavioral treatment of physical illnesses; HB 656 by mental health and substance abuse treat- physician. Further, it is estimated that healthcare benefits may limit the effi- Rep. Garnet Coleman (Houston) and SB 568 ment costs totaled $104 billion and rep- 11%-36% of patients presenting at pri- cacy of disease management programs by Senator Rodney Ellis (Houston). Other resented 7.6% of total healthcare mary care have a mental illness. for individuals with co-morbid medical “partial parity” bills filed so far include: HB spending in the United States ($1.4 Numerous studies over the past two and behavioral health conditions. 510 by Rep. Farabee (children); HB 659 and trillion). Unlike other medical conditions decades have found that the adequacy Disease management programs will not HB 1128 by Rep. Coleman (anorexia and such as heart disease or diabetes, the and quality of mental healthcare deliv- realize their full potential without fos- bulimia nervosa); HB 919 by Rep. Eissler indirect costs associated with mental ill- ered in the general medical setting is sub- tering better coordination between the (children); and SB 92 by Senator Van de Putte ness and substance abuse disorders com- optimal. In fact, the National general medical healthcare system and (anorexia and bulimia nervosa). monly meet or exceed the direct Co-morbidity Survey Replication (NCS-R) the specialty behavioral healthcare In the 2007 Texas legislative session, it is treatment costs. found that only 12.7% of individuals system. Research has shown that expected that the business community will 2. Research has conclusively shown that treated in the general medical sector individuals with chronic medical join psychiatrists, advocates and families in depression and other mental illness and received minimally adequate care com- conditions and untreated co-morbid efforts to pass legislation calling for equal substance abuse disorders are a major pared to 43.87% of patients treated in the mental illness or substance abuse cause of lost productivity and absen- specialty mental health sector. disorders are the most complicated amid benefits for mental illnesses. As a result, the teeism. Mental illness causes more days 6. Primary care physicians (PCPs) and costly cases. For example: word “parity” will be de-emphasized because of work loss and work impairment than other general medical providers are — of negative connotations to the business • Healthcare use and healthcare costs many other chronic conditions such as and will continue to be — an integral are up to twice as high among dia- community and instead, there will be a call part of behavioral healthcare in the diabetes, asthma, and arthritis. betes and heart disease patients with for “equal benefits.” This subtle change in Approximately 217 million days of work United States. However, significant qual- co-morbid depression, compared to terminology is intended to be more accept- are lost annually due to productivity ity problems have been found with gen- those without depression, even when able to the business community, which is the decline related to mental illness and sub- eral medical providers screening, accounting for other factors such as major purchaser of health insurance and can stance abuse disorders, costing United treatment, and monitoring practices. age, gender, and other illnesses. be a strong ally on this issue. States employers $17 billion each year. In Many of the recommendations presented One tool that will be used in making the total, estimates of the indirect costs asso- in the Guide suggest programs, benefits, • Patients with mental illness and sub- case for “equal benefits” is a recently pub- ciated with mental illness and substance and practices that will support general stance abuse disorders are often less lished “Employer’s Guide to Behavioral abuse disorders range from a low of $79 medical providers in the provision of responsive to treatment. For example, Health Services.” billion per year to a high of $105 billion high-quality behavioral healthcare serv- depressed patients are three times as ices. The Guide was published by the National per year (both figures based on 1990 dol- likely as non-depressed patients to be lars). 7. Psychotropic drugs have become the non-compliant with their medical 3. Disability costs related to psychiatric major treatment modality in behavioral treatment regimen. NSIDE disorders are high and continue to rise. healthcare whether prescribed by gen- I • The presence of type 2 diabetes nearly Mental illness and substance abuse dis- eral medical physicians (e.g., primary 2007 Texas Legislature ...... 7 doubles an individual’s risk of depres- orders represent the top 5 causes of dis- care physicians) or by behavioral health APA Fellowship ...... 2 ability among people age 15-44 in the specialists (i.e. psychiatrists). The avail- sion and an estimated 28.5% of dia- Calendar of Meetings ...... 8 United States and Canada (not including ability of prescription medications as a betic patients in the United States meet criteria for clinical depression. From the Federation ...... 8 disability caused by communicable dis- method of treatment has improved the eases) [Note: includes employed and lives of many individuals with mental ill- • Approximately one in six patients Hurricane Recovery Program ...... 2 unemployed populations]. Further, men- ness and substance abuse disorders. treated for a heart attack experiences In Memoriam ...... 2 tal illness and substance abuse disorders, However, a number of quality problems major depression soon after their Membership Changes ...... 2 combined as a group, are the fifth leading have been identified with current psy- heart attack and at least one in three cause of short-term disability and the chotropic medication prescribing prac- Prescribing Medications: patients have significant symptoms of third leading cause of long-term disabil- tices (e.g., pharmacological management the True Brass Tacks ...... 4 depression. is frequently the sole treatment modal- ity for employers in the United States. 9. Access to specialty mental healthcare TSCAP Summer Conference ...... 5 4. The efficacy of treatment for mental ill- ity). Further, the escalating cost of psy- services is constrained due to benefit ness and substance abuse disorders is chotropic drugs is of concern to TSPP Spring Meeting ...... 3 design with higher co-pays, visit limits, well documented and has improved employers. In 1987, psychotropic med- Volunteers Make the dramatically over the past 50 years. For ications were responsible for 7.7% of all World Go Around ...... 2 continued on page 6 TXPsychiatrist FebMar07 2/20/07 6:32 PM Page 2

Volunteers Make the World Go Around Leslie H. Secrest, MD, President, Texas Society of Psychiatric Physicians

s your President, I have been part of our expectation. If the list of commit- In fact without even one of them, we would Aimpressed by the contributions made tees is scanned, the contribution made by see a blemish in the fabric until a new mem- by TSPP members and the members of our any one member will not be readily appar- ber arrives and contributes to the dialogue. Chapters. Members not only provide the ent. The discussions that transpired may be Being a part of the fabric year after year can financial support for our infrastructure but known only by those in attendance. be tiring and at times disheartening as the Leslie H. Secrest, MD also become the energy and muscle that Occasionally there will be an action item energy and contributions may seem to be moves our organizations forward. Meeting which will spring forth to move to another unappreciated or unacknowledged. together as Psychiatrists we talk about and committee and ultimately an action or posi- The amazing part of all this is that mem- the boredom of the routine. Experiencing find ways to assist our communities, our tion will be taken. Throughout this process bers return year after year and can spend a our membership and our volunteerism as patients, and our profession through volun- each contribution is extremely valuable as life time being the fabric with very little enjoyable brings a certain serenity that teer activities. The vitality of Organized the dialogue brings clarity and considera- acknowledgement and yet quickly spring invigorates, that energizes, that excites, and Psychiatry and Organized Medicine relies on tion. Often the individuals who contributed forward when there is a new need that that returns us again. Focusing on and fos- our volunteer activities. Quite often volun- their expertise, experience and point of view requires the expenditure of more volunteer tering satisfaction is some of our challenge. teers and their contributions each day are can never be fully and formally acknowl- resources. A legislative year is often a time The satisfaction and serenity that members over looked unless those activities happen to edged. Scanning the committee list again when there is a sudden need for the recruit- experience in their daily volunteering nur- solicit our collective attention. with the question what has this committee ment and expenditure of volunteer tures the strength in our organizations. Unfortunately, some of the most important done lately, an answer quickly emerges. The resources. Not to say that the off year doesn’t TSPP and the Chapters are leaders locally, contributions go unnoticed because they work of committee members have provided often demand a quick mobilization of leaders in the state and leaders nationally. At become part of the structure and expecta- the structure and the process that creates resources. Our individual resources are the times we fail to give our selves credit for tion of the organization. what we are. Members are the fabric and most precious ones we have, our time, our what we achieve. As an organization we are a The committee work in TSPP and the without them and their contributions we intellect, our creativity, our emotions and valued resource, providing leadership and Chapters can be over looked because it is would not be strong, effective, and efficient. our energy. The return on our expenditure is thoughtful vision. Now that we are in the the satisfaction that by combining our midst of the legislative session, please plan Hurricane Recovery Program unique individual contributions, public pol- to attend our Capitol Day, February 28th. icy is affected, patient care and access is This allows our legislators to know that we Access to Care advanced, patient safety is improved, and are a special resource and readily available. The Access to Care program is a mental health and substance abuse program for people our profession is invigorated. Lastly, thanks to each of you the unsung who were impacted by Hurricanes Katrina, Rita and Wilma, and their family members. Often the enrichment, the enjoyment, the heroes and heroines who give of yourselves Survivors are able to receive financial assistance for mental health counseling, medication humor, the affection, the good times and the and quietly make TSPP and the Chapters a and substance abuse treatment during their recovery. The program can be used to pay for growth as individual members working leader and a resource to our nation, to our services with licensed providers and clinics anywhere in the country and is retroactive to together is placed in the background and is state and to our communities. You do make August 30, 2005. Anyone who resided in a FEMA designated pre-disaster hurricane zip over looked by the urgency of situations or the world go around. I code prior to landfall and suffered significant impact is eligible. Anyone who lost a close family member as a result of the hurricanes, regardless of their place of residence at the time of the hurricanes, is also eligible for assistance. Mental health professionals, case MEMBERSHIP CHANGES managers and interested clients can get more information about eligibility, covered services and how to enroll, by visiting the program’s website: www.a2care.org or by calling: TEXAS SOCIETY OF PSYCHIATRIC PHYSICIANS 1-866-794-HOPE, a 24/7 toll-free, multilingual line staffed with trained mental health The following membership applications have been approved by the TSPP Executive professionals. Committee and have been transmitted to the APA. This program is an initiative of The American Red Cross Hurricane Recovery Program and Member in Training Regwan, Heather, MD, Helotes is administered by Link2Health Solutions, a private non-profit subsidiary of The Mental Afzal, Khalid, MD, El Paso Salib, Micael, MD, El Paso Health Association of NYC. Garza, Magdalene, MD, Shakil, Rubina, MD, Austin Gonzalez, Sylvia, MD, Spring Sullivan, Joachim, MD, Temple To discuss outreach opportunities or request materials or more detailed program information, Lara, Christell, MD, Galveston Vaughan, Lucretia, MD, Missouri City contact Jennifer Cronin, [email protected] or 212-614-6328. McAdams, Carrie, MD, Plano Vitali, Ariel, MD, Lubbock Moore, Audrey, MD, Houston Neal, Cheryl, MD, Houston General Member Opalacu, Thaddeus, DO, Mansfield Bushong, Criag, MD, (Reinstatement) Houston Park, Eun, MD, San Antonio Loya, Altaf, MD, Houston APA Fellowship Patel, Nishant, MD, Houston If you have been a General Member for at APA Annual Meeting in Washington DC. TEXAS ACADEMY OF PSYCHIATRY least five consecutive years, the APA invites To obtain a Fellow Application The following membership applications have been approved by the Texas Academy of Psychiatry. you to apply for Fellow status. In addition form, please contact the APA Membership General Member Member in Training to the membership requirement men- Department, 1000 Wilson Blvd., Suite 1825, Dobyns, Robert, MD, Austin Garcia-Pittman, Erica, MD, Dallas tioned, the following eligibility criteria must Arlington, VA 22209 or call 1-888-35-PSYCH. Fagala, Gwen, MD, Amarillo Opalach, Thaddeus, DO, Mansfield be met: • Certification by the American Board of Psychiatry and Neurology, the Royal College of Physicians and Surgeons of Canada, or the American Osteopathic Association. • Three letters of recommendation from current Fellows, Distinguished Fellows, Life Fellows or Distinguished Life Fellows. • 30-day review period for TSPP to offer comments about the Fellowship candi- date. • Approval by the APA Membership Committee. • Approval by the APA Board of Trustees.

To apply, you must submit an Fellowship Application form and the three letters of recommendation to the APA by September 1, 2007. Members who apply and are approved for the category of Fellow this year will officially become Fellows on January 1, 2008 and will be invited to participate in the Convocation of Distinguished Fellows during the 2008

In Memoriam... Bruce H. Beard, MD, Dallas George A. Constant, MD, Victoria

2 TEXAS PSYCHIATRIST FEBRUARY / MARCH 2007 TXPsychiatrist FebMar07 2/20/07 6:32 PM Page 3

Texas Society of Psychiatric Physicians Committee Meetings/CME Dinner Program/Executive Council Meeting April 28-29, 2007 • Adolphus Hotel • Dallas

ake plans to join your friends and TEXAS SOCIETY OF PSYCHIATRIC PHYSICIANS Mcolleagues for TSPP’s Committee TSPP has arranged a limited, Meetings, complimentary luncheon special DISCOUNTED room CME DINNER PROGRAM • APRIL 28, 2007 (underwritten by Acadia Healthcare) rate of $139.00 single or Practical Clinical Applications of the “CATIE” (Clinical and 2-hour CME $149.00 double occupancy accredited dinner for TSPP meeting attendees Antipsychotic Trials of Intervention Effectiveness) Studies program on at The Adolphus Hotel. Michael Schwartz, MD Saturday, April 28 at the award-winning FOR ROOM RESERVATIONS: REGISTRATION FEE: $35.00 PRIOR TO MARCH 28 / $45.00 AFTER MARCH 28 Adolphus Hotel, 1321 Commerce Street, 1/800/221-9083 Please complete the attached Registration Form and return with payment to Texas Society Dallas, TX. The TSPP Executive Council will BEFORE MARCH 28 of Psychiatric Physicians, 401 West 15th Street, Suite #675, Austin, TX 78701 or if paying by meet on Sunday, April 29. OR UPON SELL-OUT, credit card, fax to 512/478-5223. WHICHEVER TSPP’s committee meetings have been MEETING SITE: The Adolphus Hotel, 1321 Commerce Street, Dallas, Texas. TSPP has OCCURS FIRST. scheduled in conjunction with the TexMed arranged for a limited, discounted room rate of $139 single or $149 double occupancy at Annual Convention in Dallas and members the Adolphus until March 28 or upon sell-out, whichever occurs first. For room reserva- tions please contact the Adolphus Hotel at 1/800/221-9083. are also encouraged to attend TMA’s Section and/or register for the CME Dinner on Psychiatry Program Friday, April 27, Program, please complete the enclosed PARKING: The Adolphus offers covered, valet parking for overnight guests at a rate of $20.00 per day and includes in/out privileges. A special day rate of $12.00 (no in/out privi- 9:00am-5:00pm, at the Hyatt Regency Hotel. RSVP & Registration Form and return to the leges) is extended to attendees without room reservations. Following the conclusion of committee Texas Society of Psychiatric Physicians’ TARGET AUDIENCE: This CME program is designed in a format consisting of a lecture and meetings on Saturday, the TSPP CME Office, 401 West 15th Street, Suite 675, direct discussion and is designed to provide its’ primary target audience of Psychiatrists, as Committee has arranged a 2 hour Category Austin, TX 78701 (fax 512/478-5223) by well as other specialties of medicine, with clinically-relevant information regarding practi- 1 CME Dinner Program “Practical Clinical March 28. For additional information, cal treatment recommendations and clinical applications of the CATIE Studies. Applications of the CATIE (Clinical visit our website www.txpsych.org or OBJECTIVES: At the conclusion of this presentation participants will be able to: Antipsychotic Trials of Intervention contact our office at 512/478-0605; • Specify the evidence for differences in efficacy between first and second generation Effectiveness) Studies” by noted speaker, e-mail [email protected]. We look antipsychotics, and among the different second generation agents. Michael Schwartz, MD. forward to seeing you at the TSPP • Discuss the comparative side effect profiles for these classes of medications. To confirm your meeting attendance meetings in April. • Describe to patients the current rationale for use of antipsychotics in specific clinical situations

TEXAS SOCIETY OF PSYCHIATRIC PHYSICIANS ACCREDITATION STATEMENT: The Texas Society of Psychiatric Physicians designates this TM Committee & Executive Council Meetings & educational activity for a maximum of two AMA PRA Category 1 Credits . Physicians should only claim credit commensurate with the extent of their participation in the activity. CME Dinner Meeting “Practical Clinical Applications of the CATIE Studies” The Texas Society of Psychiatric Physicians is accredited by the Texas Medical Association April 28-29, 2007 • Adolphus Hotel to provide continuing medical education for physicians. REGISTRATION FOR ADDITIONAL INFORMATION: CONTACT TSPP AT 512/478-0605 OR E-MAIL [email protected] NAME: This program is funded in part by an educational grant from Eli Lilly and Company and ADDRESS / CITY / STATE / ZIP: AstraZeneca, which had no control over its content.

E-MAIL ADDRESS FOR MEETING CONFIRMATION: SCHEDULE YES, I will attend NO, I will not attend COMMITTEE/EXECUTIVE COUNCIL ______# Attending Luncheon - NO CHARGE - if pre-registered SATURDAY, April 28 before meeting - Underwritten by Acadia 7:30 AM - 8:00 PM Registration / Information Mezzanine Foyer Healthcare 7:30 AM - 8:55 AM Foundation Board of Directors Breakfast Mtg Directors I I Academic Psychiatry 8:00 AM - 5:00 PM DBSA I I Children and Adolescents 8:30 AM - 4:00 PM Committee Hospitality AB Constitution and Bylaws (NOT MEETING) Complimentary Refreshments & Light Hors D’oeuvres I I Continuing Medical Education For Committee Members I I Ethics 9:00 AM - 10:30 AM Socioeconomics Pat Morris Neff I I Fellowship Academic Psychiatry W. Lee O’Daniel I I Finance Finance Executive I I Forensic Psychiatry Physician Advocacy Sam Houston C I I Foundation Board of Directors 10:30 AM - 12:00 PM Professional Practices Pat Morris Neff I I Government Affairs Fellowship Executive I I Members-in-Training Section Strategic Planning & Coordinating Sam Houston C Nominating (NOT MEETING) Texas Academy of Psychiatry Membership W. Lee O’Daniel I I Physician Advocacy 12:00 PM - 1:30 PM Committee / Member Luncheon John Neely Bryan I I Professional Practices ** No Charge if Pre-Registered Prior to Meeting ** I I Public Mental Health Services Underwritten by Acadia Healthcare I I Socioeconomics (See Registration Form to Register) I I Strategic Planning & Coordinating 1:30 PM - 3:00 PM Public Mental Health Services Pat Morris Neff I I Texas Academy of Psychiatry Membership Ethics Executive $35.00 Per Person CME Dinner Program: 3:00 PM - 4:30 PM Continuing Medical Education Sam Houston C # Attending “Practical Clinical Applications of the CATIE Studies” - Michael Schwartz, MD Forensic Psychiatry Pat Morris Neff $35.00 Per Person Prior to 3/28; $45.00 AFTER Children and Adolescents Executive I I (Sunday) Executive Council Meeting Members in Training W. Lee O’Daniel 4:35 PM - 6:00 PM Government Affairs Pat Morris Neff METHOD OF PAYMENT: I Check I VISA I MasterCard I American Express 6:30 PM - 8:30 PM CME Dinner Program “Practical Clinical Applications of the CATIE Studies”, Michael Schwartz, MD AB Credit Card # Exp. Date $35.00 Per Person Prior to 3/28/07; $45.00 After 3/28 and On-Site Name of Cardholder (as it appears on card) ______(See RSVP/Registration Form to Register)

Zip Code Where You Receive Credit Card Statement ______SUNDAY, April 29 9:00 AM - 12:00 PM Executive Council Dan Moody CANCELLATION POLICY: In the event of cancellation, a full refund will be made if written notice is received in the TSPP office by March 28, 2007, less a 25% handling charge. No refunds will be given after April 15, 2007 Complimentary Continental Breakfast for Council Members MAIL / FAX FORM TO TSPP BY MARCH 28, 2007 to 401 West 15th St. # 675, Austin, TX 78701 / FAX 512/478-5223

FEBRUARY / MARCH 2007 TEXAS PSYCHIATRIST 3 TXPsychiatrist FebMar07 2/20/07 6:32 PM Page 4

Part 4 Overview and Summary Prescribing Medications: the True Brass Tacks R. Sanford Kiser, MD, President, Texas Academy of Psychiatry

re you ready for the true brass this misconception (FDA Medical Bulletin, prescriptions for the average patient. Atacks? The truth about prescribing Volume 12, Number 1, April 1982). This bul- Nonetheless in the real world we treat medications? letin states: individual patients, and not the abstract The three previous articles of this series “The appropriateness or the legality of “average” patient. Therefore the evidence for have been a warm up, and now we are ready prescribing approved drugs for uses not the best medication choice for each individ- to get down to a summary of the hard facts. included in their official labeling is some- ual patient is guided by an empirical clinical Why are hard facts so important? The times a cause of concern and confusion technique, which parallels the “N of 1” answer is obvious. In this day and time med- among practitioners. research design, in which a patient is used as ications can treat more illnesses than ever The Federal Food, Drug, and Cosmetic his/her own control for drug effects. before, but medications cost more than ever (FD&C) Act does not … limit the manner in (2) There are huge gaps in the scientific lit- which a physician may use an approved drug. erature. Despite decades of modern medical before. Physicians, patients, and third-party R. Sanford Kiser, MD pharmacy benefit managers need the best Once a product has been approved for mar- research and the vast array of clinical publi- information possible to utilize medications keting, a physician may choose to prescribe it cations, there are too many questions that that can deliver optimal results, both med- for uses or in treatment regimens or patient have not been asked, too many hypotheses ically and financially. populations that are not included in that have not been tested, and too many Unfortunately, the decision making pro- approved labeling. Such … uses may be answers that are still unknown. We delude cedures for these determinations all too appropriate and rational in certain circum- ourselves if we think we have enough infor- (“doctor shopping”). A second example is a commonly have involved processes known stances and may, in fact, reflect approaches to mation for clear-cut evidence-based pre- patient surreptitiously going from doctor to as ignorance, foolishness, claptrap, poppy- drug therapy that have been extensively scription decisions. doctor to support an addiction disorder. cock, nonsense, baloney, drivel, hogwash, reported in medical literature…. Paradoxically, our deficiencies in this area Even in straightforward cases, a complicated twaddle, garbage, bunkum, silliness, false- Valid new uses for drugs already on the are being highlighted by our successes in medication regimen can be difficult for a hood, balderdash, and deep-down dumb- market are often first discovered through pharmacogenetics and pharmacogenomics patient to follow, and differentiation between ness. serendipitous observations and therapeutic research. The discoveries in those areas are symptoms and additive side effects or drug- The phrase “getting down to brass tacks” innovations…. revealing individual variations in the coding drug interactions can be difficult. means to clear out these types of confusing With respect to its role in medical practice, in the human genome for the multitude of Nonetheless, modern research has obscurities and false generalities, in order to the package insert is informational only. FDA factors involved in both pharmacodynamics increasingly revealed detailed information find out the real truth about something. tries to assure that prescription drug informa- and pharmacokinetics. regarding drug action — all the way from Let us summarize some of the “medica- tion in the package insert accurately and fully In spite of these limitations, continuing absorption via different routes, through tion myths” that we have addressed in this reflects the data on safety and effectiveness on advances in computer and internet technol- activities at various receptors, to excretion by series. which drug approval is based.” ogy are accelerating the creation and com- different mechanisms. This information has Medication Myth #1: The “Gold Standard” The brass tacks nailing this medication munication of large databases facilitating led to an increasingly sophisticated body of for Drug Information is Found in the myth to the wall of facts is clear in this FDA evidence-based guidance in medication knowledge that has led to the development Physicians Desk Reference (PDR) bulletin. To pretend that the initial drug data decisions. The National Guideline of “rational polypharmacy” as a new stan- The True Brass Tacks: The information in for FDA approval is the totality of informa- Clearinghouse, an agency of the U.S. dard of care in many clinical situations. the PDR is limited to a summary of the infor- tion for the drug is to pretend that the first Department of Health and Human Services, A panel of experts of the National mation that the drug manufacturer submit- Caribbean island discovered by Columbus is has a compendium of practice guidelines at Association of State Mental Health Program ted to the Food and Drug Administration the totality of the New World. their website, http://www.guideline.gov. The Directors has reviewed the evidence for (FDA) for approval of the drug to be labeled Medication Myth #2: Evidence-based National Center for Biotechnology rational polypharmacy in psychiatry. A and marketed as safe and effective for a sin- Prescribing is the Only Proper Way to Information (NCBI) is a division of the summary of their findings can be found at gle condition. That information came from Prescribe Medications National Library of Medicine at the National their website, http://www.nasmhpd.org/ years of pharmaceutical research trials cost- The True Brass Tacks: In a perfect world Institutes of Health. The NCBI website, general_files/publications/med_direc- ing millions of dollars. In some cases, subse- we would have evidence-based, black-and- http://www.ncbi.nlm.nih.gov, provides tors_pubs/polypharmacy.pdf. Their sum- quent experience and research with an white answers to all medical decisions, access to powerful online clinical and basic mary describes examples of rational approved drug can yield information about including decisions about the proper research literature databases, as well as other polypharmacy practices in psychiatry sup- other beneficial uses, called “off-label” uses. choice of medications. Unfortunately we resources for evidence-based medication ported by the medical literature, including Unless a financial incentive is present, a are not in that perfect world yet; in fact our decisions. (1) multi-class polypharmacy, i.e. use of drug manufacturer is not likely to spend the world is so imperfect that different people The irony of modern medication deci- drugs of different classes to treat one condi- years or dollars required for FDA approval can have different definitions of “evidence- sions is that, in spite of all our wishes for evi- tion, (2) adjunctive polypharmacy, i.e. the and labeling for an additional indication, based medicine.” dence-based, easy answers, the true brass use of a second medication for side effects particularly if the newly discovered off-label The current state of imperfection in evi- tacks securing safe and proper patient care of another medication, and (3) augmenta- use of the medication is already widespread. dence-based approaches to prescribing deci- still lies in the time-tested importance of the tion, i.e. use a low dose of a second medica- Consequently, decision making processes sions arises primarily from two factors: individual and unique doctor-patient rela- tion to enhance the benefits of another which restrict the use of a medication only to (1) The information for evidence-based tionship. medication. the FDA labeling information in the PDR is a medication prescribing is derived from mul- Medication Myth #3: Polypharmacy is The brass tacks bottom line for “polyphar- misuse of the FDA approval process, a tiple types and levels of scientific data. The Always Bad macy” is that it is a word that can be used process which is limited to evaluation of data sources include material from the FDA The True Brass Tacks: The term loosely and inappropriately to foster safety and efficacy of the drug for a single approval process, consensus of experts, “polypharmacy” can describe a number of confusing generalities. Polypharmacy can purpose. anecdotal reports, open design studies, sin- clinical situations. Some, but not all, of those come in multiple forms, some of which The myth giving rise to this misuse of the gle blind studies, double-blind studies, situations can potentially be harmful. emerge from ignorance. However, the use of FDA approval process has been as hard to multi-center double-blind studies, and One example of potential harm is a multiple medications, derived from a dispel as the myths of Bigfoot, the Loch Ness meta-analyses of the medical literature. All patient going to multiple doctors, who pre- thoughtful, knowledgeable understanding of Monster, and the Abominable Snowman. As this information can be consolidated into scribe multiple medications for the same drug pharmacodynamics and pharmacoki- far back as a quarter of a century ago, the practice guidelines which typically set forth a condition, with none of the doctors being netics, is not just polypharmacy. It is rational FDA issued a bulletin attempting to clarify general framework for guiding medication aware of the other doctors’ prescriptions polypharmacy. I

TSCAP Summer Conference Steven R. Pliszka, MD, President, Texas Society of Child and Adolescent Psychiatry

he Texas Society of Child and of California at Los Angeles. Dr. McCracken cipals of these techniques and have a case TAdolescent Psychiatry will hold its and his faculty are some of the leading presentation of a child with comorbid annual meeting July 27-29, 2007 at the researchers in the world in the genetics of major depression and epilepsy whose Moody Gardens in Galveston, Texas. The psychiatric disorder. In the future, pharma- depression responded when his epilepsy theme of the meeting will be, “New cogenetic assays will help predict response was treated with VNS. Steven R. Pliszka, MD Directions in Child and Adolescent to treatment and identify patients vulnera- Finally, we will have a presentation and Psychiatric Treatment.” We plan to delve ble to side effects. panel discussion on psychiatric polyphar- into new advances in clinical neuroscience In the last few years, brain stimulation macy in children which will qualify as the that will shape the practice of psychiatry in tasks such as magnetoencephalography ethics credit of your continuing medical Texas psychiatrists to be aware of the cur- the next five years: pharmacogenetics, (MEG), vagal nerve stimulation (VNS) and education (CME) annual requirement. rent trends in this area. brain stimulation methods and the ethics deep brain stimulation (DBS) have been There is great public concern about the use The Moody Gardens is a beautiful and of psychopharmacology in children and developed for research into and treatment of psychotropics in children; there are a relaxing setting and is ideal for bringing the adolescents. Our keynote speaker will be of psychiatric disorder. VNS is currently growing number of complaints being file family. The society warmly invites all the James McCracken, MD, the Chief of the approved for treatment of adult depression with the Texas Medical Board against psy- members of the Federation of Texas Psych- Child Psychiatry Division of the University and epilepsy. We will review the basic prin- chiatrists on this issue. It is critical for all iatry to attend. We hope to see you there. I

4 TEXAS PSYCHIATRIST FEBRUARY / MARCH 2007 TXPsychiatrist FebMar07 2/20/07 6:32 PM Page 5

Texas Society of Child and Adolescent Psychiatry Summer Meeting and Scientific Program “New Directions in Child and Adolescent Psychiatric Treatment” MOODY GARDENS July 27-29, 2007 • Moody Gardens Hotel • Galveston

General Information At the conclusion of this program, atten- dees will be able to: PROGRAM AT A GLANCE Location All events will take place at the Moody Pharmacogenetics in Child and Adolescent Friday, July 27, 2007 Gardens Hotel, Seven Hope Boulevard, Psychiatry 1:00 pm - 5:30 pm Exhibits Set-Up Floral Hall A-1 Galveston, Texas, 1/800/582-4673. • Understand the basic principles of phar- 4:00 pm - 5:30 pm Executive Cmte Business Mtg Iris 6:30 pm - 8:00 pm Opening Welcome Reception with Exhibitors Floral Hall A-1 Surrounded by 242 acres of breathtaking macogenetics. gardens and majestic pyramids, the Four • Discuss how pharmacogenetics affects the Saturday, July 28, 2007 Diamond Moody Gardens Hotel, Spa and tolerability of psychotropic medications. 7:00 am - 3:30 pm Exhibits Floral Hall A-1 7:30 am - 8:30 am Complimentary Continental Breakfast Floral Hall A-2 Convention Center is Galveston Island’s • Discuss research to predict treatment with Exhibitors premier meeting destination. Moody response in child and adolescent psychia- Gardens features: the ten story Rain Forest try using pharmacogenetics. Pyramid, the IMAX 3D Theater,the Scientific Program: Discovery Museum,the IMAX Ridefilm Brain Stimulation Technologies in Psychiatry NEW DIRECTIONS IN CHILD AND ADOLESCENT PSYCHIATRIC TREATMENT Theaters, Palm Beach - Moody Gardens • Understand the basic principles of vagus 8:15 am - 8:30 am Welcome and Announcements Floral Hall A-2 secluded fresh water, white sand beach fea- nerve stimulation (VNS) and transmag- 8:30 am - 10:30 am Pharmacogenetics in Child and Floral Hall A-2 Adolescent Psychiatry turing crashing waterfalls, crystal clear netic Stimulation. Jim McCracken, MD lagoons, Jacuzzi’s, volleyball courts and • Know the indications for VNS. 10:30 am - 10:50 am Refreshment Break w/Exhibitors Floral Hall A-1 paddleboats, the Colonel Paddlewheel Boat • Discuss current research in new brain 10:50 am - 11:50 am Brain Stimulation Technologies in Psychiatry Floral Hall A-2 and the Aquarium. stimulation techniques. Sarah Sacha, DO Golf and tennis facilities are available to 11:50 am - 12:00 pm Break / Lunch Set-Up Moody Gardens guests at the Galveston Case Presentation of VNS 12:00 pm - 2:15 pm Luncheon Program: Case Presentation of VNS Floral Hall A-2 Country Club. The hotel concierge will make • Discuss how VNS is used to treat epilepsy Resident Case Presentation - arrangements for you. in children. Presenter: James Boger, MD / • Discuss possible psychological effects of Discussants:Valerie Robinson, MD and Sarah Sacha, DO Hotel Reservations 2:15 pm - 2:30 pm Break TSCAP has arranged a limited, special dis- VNS in epileptic children. 2:30 pm - 3:30 pm Use of Multiple Psychopharmacological Floral Hall A-2 counted room rate for conference attendees • Discuss the interaction of VNS with a child’s psychopharmacological treatment. Agents in the Child with Severe Aggression at the Moody Gardens Hotel of $175.00 single and/or Mood Lability - quad occupancy until July 5, or upon sell- Use of Multiple Psychopharmacological Steven Pliszka, MD out of the discounted room block, whichever Agents in the Child with Severe Aggression 3:30 pm - 4:30 pm Exhibitors Depart Floral Hall A-1 occurs first. and/or Mood Lability To place your reservation call (888) 388- Sunday - July 29, 2007 • Review the current literature on the use of 8484 and identify yourself as an attendee of 8:00 am - 9:00 am Membership Business Meeting Breakfast Floral Hall A-1 multiple agents in severe psychiatric disor- the Texas Society of Child and Adolescents ders. Scientific Program Conference. 9:15 am - 10:15 am The Ethics of the Use of Multiple Floral Hall A-2 Check-In Time: 4:00 pm • Discuss barriers to the research on the Psychopharmacologic Agents in the Check-Out Time: 12 effectiveness of two or more medications in psychiatric disorder. Treatment of Children and Adolescents Sarghi Sharma, MD Opening Welcome Reception • Discuss recent guidelines issues by the 10:15 am - 10:30 am Refreshment Break with Exhibitors Texas State Department of Health Services 10:30 am - 11:30 am Panel Discussion: Medical-Legal Issues Floral Hall A-2 A special Welcome Reception has been for the use of multiple psychotropic agents Surrounding the Use of Multiple planned to open the event, Friday, July 27, for foster children. beginning at 6:30 pm until 8:00 pm in Floral Psychopharmacological Agents in Children and Adolescents Hall A-1 at the Moody Gardens Hotel. The Ethics of the Use of Multiple Psychophar- macologic Agents in the Treatment of Children Steven Pliszka, MD and Randall Sellers, MD 11:30 am - 11:35 am Closing Remarks / Adjourn Continuing Medical Education and Adolescents • Discuss the standards for off label use of Accreditation psychotropic medication in children and CME / SCIENTIFIC PROGRAM / LUNCHEON This activity has been planned and imple- adolescents. mented in accordance with the Essential Fax Back (512) 478-5223 or Mail: 401 West 15th Street, Suite #675, Austin, TX 78701; Questions • Distinguish research from pharmaceutical Areas and Policies of the Texas Medical or Special Assistance: Call Debbie Sundberg (512) 478-0605 or E-Mail: [email protected] company marketing in dosing and selec- Association (TMA) through the Joint tion of agent. Sponsorship of the Texas Society of NAME DEGREE Psychiatric Physicians and the Texas Society • Discuss informed consent issues related to of Child and Adolescent Psychiatry. The Texas long term side effects with poly- MAILING ADDRESS CITY STATE ZIP Society of Psychiatric Physicians is accredited Psychopharmacology. TELEPHONE NUMBER FAX NUMBER by the Texas Medical Association to provide Panel Discussion: Medical-Legal Issues continuing medical education for physicians. Surrounding the Use of Multiple Psychophar- E-MAIL The Texas Society of Psychiatric Physicians macological Agents in Children and Adolescents designates this educational activity for a max- • Discuss how standard of care is arrived at NAME OF SPOUSE/GUEST(S) ATTENDING WELCOME RECEPTION imum of eight (8) AMA PRA Category 1 and how peer review determines if care is Conference fee includes the Saturday and Sunday Scientific Program; the Friday evening TM Credits . substandard. welcome reception; the Saturday and Sunday continental breakfasts and Saturday luncheon. Participants should only claim credit com- • Discuss current development in the politi- mensurate with the extent of their participa- REGISTRATION Before July 14 After July 14 cal process regarding regulation of tion in the activity. TSCAP Member Physician $195 $215 ______Psychiatric treatment. The presentations “The Ethics of the Use Non-Member Physician $250 $270 ______of Multiple Psychopharmacologic Agents in • Provide input to colleagues on current Allied Health Professional $180 $200 ______the Treatment of Children and Adolescents practices in the psychopharmacology of Trainee - Member/Non-Member No Fee $30 ______Children and adolescents. and Panel Discussion: Medical-Legal Issues SOCIAL EVENTS Surrounding the Use of Multiple Friday Welcome Reception Featured Speakers / Discussants Psychopharmacological Agents in Children I Friday Welcome Reception – indicate if attending and if bringing any Guests, and Adolescents” has been designated by the James Boger, MD – Resident Instructor, PGY 3, Department of Neuropsychiatry - Lubbock, if so, their Name(s): ______Texas Society of Psychiatric Physicians for two I TTUHSC, School of Medicine Saturday Scientific Program Luncheon, indicate if attending (2) hours of education in medical ethics I Sunday Membership Breakfast, indicate if attending James McCracken, MD – Director, Department of and/or professional responsibility. TOTAL REGISTRATION Child and Adolescent Psychiatry, UCLA, Los Angeles, California Scientific Program Target Audience / P AYMENT INFORMATION Program Goals and Objectives Steven Pliszka, MD – Professor and Deputy Chair, Method of Payment - Make checks payable to “TSCAP” Department of Psychiatry, UTHSCSA, San Antonio The primary target audience of the program I Check I VISA I MasterCard Credit Card consists of Child and Adolescent Valerie Robinson, MD – Assistant Professor, #______Exp. Date ______Psychiatrists, Psychiatrists and other special- Department of Neuropsychiatry - Lubbock, ties of medicine. This continuing medical TTUHSC, School of Medicine Name of Cardholder (as it appears on card) ______education activity will be presented in a class- Sarah Sacha, DO – Assistant Professor, Signature______room style format, with didactic lectures sup- Department of Psychiatry, UTHSCSA, San Antonio plemented with audiovisual presentations, Sarghi Sharma, MD Credit Card Billing Address ______ADDRESS CITY STATE ZIP case presentations and question and answer Assistant Professor, Department of CANCELLATIONS – Deadline for cancellation is July 14, 2007. In the event of cancellation, a full refund will be made if written notice discussions. Psychiatry/Behavioral Sciences, UTMB, Galveston is received in the TSCAP office by July 14, 2007, less a 25% handling charge. NO REFUNDS WILL BE GIVEN AFTER JULY 14, 2007.

FEBRUARY / MARCH 2007 TEXAS PSYCHIATRIST 5 TXPsychiatrist FebMar07 2/20/07 6:32 PM Page 6

Seeking Equal Benefits for Psychiatric Illnesses continued from page 1 dardized and integrated behavioral health benefit structures behavioral health treatment modali- health services. b. Reimbursement for Non- ties and make recommendations and management of utilization.These The recommendations featured in the Psychiatrist Physicians - about whether new treatment modali- additional financial limitations are not Guide are meant to guide employers as Reimburse primary care and other ties should be added to employers’ applied to psychotropic drug benefits or they develop their medical and behav- non-psychiatrist physicians for benefit structures. to many behavioral health interven- ioral health benefit plans. Employers are screening, assessing, and diagnos- II. Recommendations Directed at tions delivered in the general healthcare encouraged to add these recommenda- ing mental illness and substance Disability Management Vendors and setting. This has created a perverse tions to contract language with Managed abuse disorders, [Rules and policies Services incentive for patients to a.) access mental Care Organizations (MCOs), Managed regarding the payment of non-psy- 6. Recommendations to Improve healthcare from general healthcare Behavioral Health Organizations chiatrist physicians (e.g., primary Employer Management of Behavioral providers (where there are no visit limita- (MBHOs), Pharmacy Benefit Managers care physicians) for the treatment Health Disorders that Qualify for tions and co-pays are significantly lower) (PBMs) and/or Disability carriers as of mental illness and substance Short- and/or Long-Term Disability and to b.) rely on psychotropic medica- appropriate. Adoption of the recommen- abuse disorders should be well Benefits tion as an exclusive method of treatment. dations will require employers to change publicized to primary care physi- a. Review short-term and long-term 10. Limiting behavioral healthcare services their vendor contract language and to cians, other non-mental health disability management programs can increase employers’ non-behavioral make changes to their benefit structures. providers, and their clinical/busi- and instruct vendors to actively direct and indirect healthcare costs. One Adoption of recommendations regarding ness administrators.] manage all behavioral health dis- study found that limiting employer- best-practice implementation and qual- 4. Recommendations to Improve the ability claims. sponsored specialty behavioral health ity improvement measures will necessi- Accuracy and Quality of Prescribing • Involve a behavioral health spe- services increased the direct medical tate that employers instruct their MCOs, Psychotropic Medications in the cialist in certification of psychi- costs of beneficiaries who used behav- MBHOs, PBMs to track patient and General Medical and Specialty atric disability and treatment ioral healthcare services by as much as provider data. Wherever possible, the Behavioral Healthcare System planning. 37%. Further, the specialty behavioral management vendors should incorpo- a. Adoption of a national best-prac- • Involve a behavioral health spe- health service limitation substantially rate the recommended standards as a tice guideline for the prescribing cialist in the review of the treat- increased the number of sick days taken part of their normal provider perform- and monitoring of psychiatric ment plan. by employees with behavioral health ance review. Employers should require drug interventions - Require • Refer employees on disability for problems. The study concluded that sav- these vendors to present their findings of MCOs, MBHOs, and PBMs to adopt a psychiatric condition to EAP ings attributed to limiting behavioral these reviews annually. a national best-practice guideline for return-to-work assistance. health benefits were fully offset by 1. Recommendations to Improve the for the prescribing and monitoring III. Recommendations to Improve increased use of other medical services Delivery of Covered Behavioral of psychiatric drug interventions. Employee Assistance Program Services 7. Recommendations to Improve the and lost workdays. Healthcare Services in the General b. Annual assessment of provider Structure of Employee Assistance 11. Employers have tightly managed behav- Medical Setting performance in relation to the Programs (EAPs) ioral health benefits delivered by the a. Documentation and Monitoring - nationally accepted standard a. Reduce redundancies between specialty mental healthcare system, but Document diagnosis upon initia- best-practice guideline chosen - EAPs and health plans by re- have not as yet implemented compre- tion of treatment. Require MCOs, MBHOs, and PBMs structuring EAPs. EAPs should not hensive and integrated management b. Addressing the High-Risk of Co- to annually assess their provider’s duplicate services offered programs to address quality and costs Morbidity - Screen for depression performance in relation to the through the health plan (MCOs for psychotropic drugs and behavioral and other common behavioral nationally accepted standard best- and MBHOs), but should be re- health services delivered by general health conditions among individu- practice guideline they have cho- structured, if necessary, to pro- medical providers. Specialty mental als with chronic medical illnesses. sen (4a) [Employers should also vide the following functions: health services have been managed c. The Importance of Tracking require that their healthcare man- • Support management in tightly by managed care systems over the Patient Progress - Monitor patient agers (i.e. MCOs, MBHOs, and addressing issues of productivity past two decades. Utilization review tech- progress with standardized evi- PBMs) to provide them with a sum- and absenteeism that may be niques and other methods have reduced dence-based instruments. mary of the data collected, prob- caused by psychosocial prob- the percent of total healthcare dollars Reimburse patient monitoring as a lems that were identified, and the lems. employers spend on mental healthcare lab test. performance plan improvement to • Assist in the design and devel- benefits. In fact, private employers expe- d. Collaborative Care - Use the col- address these problems, annually.] opment of a structured program rienced a 50% decline in their mental laborative care model to address c. Periodic Review of Formulary - to deliver health promotion and healthcare premiums (not including the the needs of patients with mental Periodically review the formulary healthcare education tools that cost of psychotropic drugs) during the illness and/or substance abuse dis- and make adjustments as neces- significantly affect employee l990s: the average cost of private employ- orders who are receiving treatment sary based on information gar- and beneficiary health and pro- ers’ behavioral healthcare premiums in primary care. nered from the assessment ductivity and lead the effort to dropped from 6.1% of total claims costs 2. Recommendations to Improve suggested in 4b. deliver behavioral healthcare in 1988 to 3.2% in 1998. Yet, employers Collaboration Between Providers in 5. Recommendations to Improve education programs. have not adequately managed the cost or the General Healthcare System and Behavioral Healthcare Services for • Functionally coordinate with quality of behavioral healthcare services the Specialty Behavioral Healthcare Individuals with Serious Mental other health services including delivered in the general medical setting System Illness health plan, disability manage- despite the high proportion of patients a. Referrals to the Specialty a. Evidence-Based Treatment ment, and health promotion. treated for behavioral disorders in the Behavioral Healthcare System - Modalities for the Seriously b. Based on all analysis of current general medical setting. Further, employ- Coordination of care upon referral Mentally Ill (SMI) - Provide cover- EAP services, the NCESBHS found ers are not receiving good value for their from primary care to specialty age for evidence-based treatment that an important function that investment in psychotropic drugs. behavioral healthcare. modalities for seriously mentally ill EAPs provide is assessment and 12. The lack of coordination and integra- b. Improving the Collaboration children and adults. Such evi- short-term counseling for individ- tion among managed care vendors of Between Disease Management dence-based modalities include: uals at risk of mental illness and employers (MCOs, MHBOs, EMs, Programs, General Medical Care, • Targeted clinical case manage- substance abuse disorders and PBMs, and others) has created signifi- and Specialty Behavioral ment services; those with problems of daily living cant quality and accountability prob- Healthcare - Employers should • Assertive community treatment (e.g., divorce counseling, grief lems. Employers can address these require their disease management (ACT) programs; processes). In the restructuring of problems by improving the design of vendors, as part of their regular • Therapeutic nursery services; and EAP,as recommended in 7a, it is their health insurance benefit struc- practice, to periodically screen all • Therapeutic group home services. essential that these services be tures, and by requiring their behavioral patients enrolled in their respective b. Providers of Evidence-Based retained and provided by an EAP health vendors and managers to coordi- programs for common behavioral Treatment Modalities for the or other entity. nate with one another. health conditions, and coordinate Seriously Mentally Ill (SMI) - Direct c. Conduct periodic organizational care with other providers as indi- MCOs and MBHOs to add providers assessments to evaluate the effects Recommendations cated. that can deliver the evidence-based of work organization on employee I. Recommendations Directed at Health 3. Recommendations to Improve treatment modalities described in 5a health status, productivity, and Plan Benefits and Services Benefit Design for Behavioral Health to their networks. job satisfaction. The key findings described above guided Screening and Treatment Services c. Annual Review of Behavioral Health For a copy of “An Employer’s Guide to the development of the Committee’s rec- a. Equalizing Benefits Structures - Treatment Modalities - Direct MCOs Behavioral Health Services”, visit the ommendations for the delivery of stan- Equalize medical and behavioral and/or MBHOs to annually review Federation’s website at www.txpsych.org. I

6 TEXAS PSYCHIATRIST FEBRUARY / MARCH 2007 TXPsychiatrist FebMar07 2/20/07 6:32 PM Page 7

BILL SUMMARIES 2007 Texas Legislature he following is a sampling of some of disorder under the same terms and condi- information relating to the availability of SUBSTANCE ABUSE Tthe bills that have been filed to date by tions as coverage provided for physical ill- health benefits to children under the child HB 437, Ruth Jones McClendon — PRAC- members of the Texas Legislature and that nesses. health plan and Medicaid programs. The TICE GUIDELINES: The Texas Medical are being tracked by the Federation. A more HB 656, HB 659, Garnet Coleman — MH eligibility period for a child under the child Board is to establish guidelines for the complete listing of bills is available on the INSURANCE: Requires health benefit plans health plan shall be the earlier of 12 months treatment of severe acute or chronic pain Federation’s website (www.txpsych.org) to provide coverage for the diagnosis and or until the child is 19 years of age. by a physician. The guidelines shall apply under Public Policy. treatment of mental disorders under the HB 1069, Bill Zedler — BALANCED without regard to a patient’s prior or cur- same terms and conditions as coverage BILLING: Each benefit plan that provides rent chemical dependency or addiction, ALLIED HEALTH provided for the diagnosis and treatment health care through a provider network but may include standards and procedures HB 1096, Rob Orr — ADVANCED NURSE of physical illnesses. shall provide notice to its enrollees that a applicable to patients with prior or current PRACTITIONERS AND PHYSICIAN ASSIS- HB 1128, Garnet Coleman — MH INSUR- facility-based physician or other health care chemical dependency or addiction. TANTS: Increases from 3 to 6 the number of ANCE: Adds anorexia nervosa and bulimia practitioner may not be included in the HB 574, Ruth Jones McClendon — advance nurse practitioners and physician nervosa to the list of “serious mental ill- health plan’s provider network such facility- PATIENT’S BILL OF RIGHTS IN PAIN assistants that may be supervised by a ness” mandated for coverage under health based providers may balance bill the TREATMENT: A patient who suffers from physician for prescribing privileges and benefit plans. enrollee for amounts not paid by the health severe chronic or acute pain may request or removes the requirement that the supervis- benefit plan. Balance billing means the reject the use of any or all modalities to ing physician be on site. HB 664, Dawnna Dukes — HMO’s: All cov- practice of charging an enrollee in a health ered services offered by an HMO must be relieve the pain; choose from the appropri- benefit plan that uses a provider network to ate pharmacologic treatment options to HB 1546, Jodie Laubenberg — PSYCHOLOGY: sufficient in number and location to be recover from the enrollee the balance of a relieve the pain, including opiate medica- A psychologist may delegate to a qualified readily available and accessible within the non-network health care provider’s fee for tions, without first having to submit to sur- and properly trained person acting under the service area to all enrollees. An HMO shall service received by the enrollee from the gery or a medical procedure that results in psychologist’s supervision any psychological make general, special and psychiatric hos- health care provider that is not fully reim- the destruction of a nerve or other body tis- test or service that a reasonable and prudent pital care available and accessible 24 hours bursed by the enrollee’s health benefit plan. sue or the implantation of a drug delivery psychologist could delegate within the scope a day, seven days a week, within the HMO system or device; and ask the patient’s of sound psychological judgement if the psy- service area. An HMO shall arrange for cov- HB 1169, Garnet Coleman; SB 481, Leticia physician to provide an identifying notice chologist determines that: the test or service ered health care services, including refer- Van de Putte INSURANCE: Regardless of of a prescription to treat the pain for the can be properly and safely performed by the rals to specialists, to be accessible to whether a health benefit plan provides purposes of emergency treatment of law person; the person does not represent to the enrollees on a timely basis. A physician or mental health coverage, a health benefit enforcement identification. A physician public that the person is authorized to prac- provider who submits a claim to and plan must provide coverage for an enrollee, may refuse to prescribe opiate medication tice psychology; and the test or service will accepts payment from an HMO may not from birth through the date the enrollee is for a patient who requests that treatment be performed in the customary manner and bill the enrollee for the services for which 18 years of age, for a physical injury to the for severe chronic or acute pain only if the in compliance with any other law. The dele- the claim was made. enrollee that is self-inflicted in an attempt gating psychologist remains responsible for to commit suicide or by an enrollee with a physician provides the patient with the HB 839, Craig Eiland — REGULATION OF the psychological test or service performed serious mental illness. name of another physician who is qualified by the person to whom the test or service is SECONDARY MARKET FOR PHYSICIAN to treat the pain employing methods that HB 1224, John Davis; SB 419, Eddie Lucio, delegated. The psychology licensing board DISCOUNTS: Each contracting agent (a include the use of opiates. Jr. — MH INSURANCE: Requires a health may not adopt a rule that operates as an covered entity engaged, for monetary or benefit plan to provide coverage for autism LEGAL absolute prohibition or restriction on the other consideration, in leasing, selling, spectrum disorder. Autsim spectrum disor- HB 1534, Elliott Naishtat — MEDICAL USE delegation of psychological acts. transferring, aggregating, assigning, or oth- erwise conveying a physician or physician der means a neurobiological disorder that OF MARIHUANA: It is not an affirmative includes autism, Asperger syndrome or defense to prosecution for the possession MENTAL HEALTH panel to provide health care services to beneficiaries) must register with the Dept. Pervasive Developmental Disorder. of marihuana that the person possessed the HB 40, John Davis — EMERGENCY DETEN- marihuana as a patient of a physician of Insurance. To be eligible to claim a dis- HB 1436, Patrick Rose — MH INSURANCE: TION: A physician may order the trans- licensed to practice medicine in this state counted rate after execution of a contract, Requires health benefit plans to provide portation of a person to an inpatient pursuant to the recommendation of that a payer must be added to the contract coverage for eating disorders mental health facility if the physician exam- through separate amendment that is signed physician for the amelioration of the symp- ined the person within 24 hours and the by the affected physician. The contract SB 92, Leticia Van de Putte — MH INSUR- toms or effects of a bona fide medical con- physician concludes from the examination amendment must be presented to the ANCE: Adds anorexia nervosa and bulimia dition. A physician may not be denied any that the person is mentally ill and there is a physician for the physician’s signature not nervosa to the list of “serious mental ill- right or privilege or be subject to any disci- substantial risk of serious harm to the per- later than the 90th day before the date of ness” mandated for coverage under health plinary action solely for making a written or son or others unless the person is immedi- any anticipated disclosure, sale, transfer, benefit plans. oral statement that, in the physician’s pro- ately restrained. The physician shall aggregation, assignment, or conveyance to SB 380, Leticia Van de Putte — BALANCED fessional opinion, the potential benefits of marihuana would likely outweigh the immediately file an application for deten- the payer of the physician’s discounted rate. BILLING: Each benefit plan that provides health risks for a particular patient. tion within the facility after the person is A payer may not claim or otherwise offer a health care through a provider network transported. physician’s specific contracted rate for serv- shall provide notice to its enrollees that a SB 249, Rodney Ellis — DEATH PENALTY: HB 452, Paul Moreno — LOCAL MENTAL ices except to the extent that the rate is facility-based physician or other health care Prohibits a death sentence of a defendant, HEALTH AUTHORITIES: Allows a local based on the contract that directly controls practitioner may not be included in the who at the time of the commission of the mental health authority to contract for payment for services provided to the health plan’s provider network such facility- capital offense, was a person with mental services from: 1) a subsidiary of the local patient and is stated on the explanation of based providers may balance bill the retardation. A pre-trial hearing must find mental health authority; 2) an entity for- benefits or remittance advice and on any enrollee for amounts not paid by the health that the defendant was a person with men- merly a subsidiary of the local mental patient identification card issued to the benefit plan. Balance billing means the tal retardation at the time the capital health authority; 3) an entity affiliated with patient. practice of charging an enrollee in a health offense was committed. a subsidiary of the mental health authority; HB 919, Rob Eissler — MH INSURANCE: benefit plan that uses a provider network to SB 440, Bob Deuell — MAXIMUM PERIOD 4) an entity to which a treatment facility of Requires health benefit plans established recover from the enrollee the balance of a OF COMMITMENT DETERMINED BY MAX- the local mental health authority or its sub- by the Teacher Retirement System to pro- non-network health care provider’s fee for IMUM TERM FOR OFFENSE: A defendant sidiary has been sold or transferred; or 5) vide coverage for an enrollee who is a child service received by the enrollee from the may not be committed to a mental hospital an entity that has on its governing board a for the diagnosis and treatment of anorexia health care provider that is not fully reim- or other inpatient or residential facility for a member of a governing board of the local nervosa and bulimia nervosa. Such cover- bursed by the enrollee’s health benefit plan. cumulative period that exceeds the maxi- mental health authority or its subsidiary. mum term provided by law for the offense age must be the same as coverage for physi- SB 568, Rodney Ellis — MH INSURANCE: for which the defendant was to be tried. On HB 518, Elliott Naishtat — EMERGENCY cal illnesses. Requires health benefit plans to provide cov- expiration of the maximum term, the DETENTION/PRELIMINARY EXAMINA- HB 1003, Helen Giddings — WORKERS erage for the diagnosis and treatment of defendant may be confined for an addi- TION: Extends the time period allowed for COMP: Utilization review agents perform- mental disorders under the same terms and tional period in a mental hospital or other detaining a person for a preliminary exami- ing reviews of health care services under conditions as coverage provided for the diag- inpatient or residential facility only pur- nation from 24 hours to 48 hours. SB 261 Worker’s Compensation must be doctors nosis and treatment of physical illnesses. suant to civil commitment procedures. Judith Zaffirini EMERGENCY DETENTION: licensed to practice in Texas. CHILDREN OTHER Specifies that jails or nonmedical facilities HB 1051, Elliott Naishtat — MEDICAID HB 1111, Sylvester Turner — TEXAS YOUTH used to detain persons charged with or AND CHIP: For Medicaid and child health HB 414, Rob Eissler — PHYSICIAN’S PRO- COMMISSION: The TYC may not allow a convicted of a crime are not a suitable facil- plan programs, HHSC shall establish FILE: The Texas Medical Board is to remove child committed to it to participate in a ity for detention of persons taken into cus- provider payment rates that are at or above any record of a disciplinary action for an medical, psychiatric or other type of tody under mental health detention. the level established during the state fiscal administrative violation if the violation research programs. biennium beginning September 1, 2002, occurred more than five years from the ECONOMIC apply annual inflation increases to provider HB 1113, Sylvester Turner — JUVENILE annual review of a physician’s profile. HB 510, David Farabee — MH INSURANCE: payment rates and enact a plan to bring PROBATION SYSTEM: The juvenile proba- SB 30, Jane Nelson — TEXAS MEDICAL Requires health benefit plans to provide provider payment rates to Medicare levels. tion system may not allow a child within its BOARD: A license applicant who is not a coverage for an enrolleee who is a child for HHSC is to implement a community out- system to participate in a medical, psychi- the diagnosis and treatment of a mental reach and education campaign to provide atric or other type of research programs. continued on page 8

FEBRUARY / MARCH 2007 TEXAS PSYCHIATRIST 7 TXPsychiatrist FebMar07 2/20/07 6:32 PM Page 8

T E R A I O N D O E F F

# # From the Federation... T E Y X R J. Clay Sawyer, MD, Chairman, Federation of Texas Psychiatry A T S I A P S Y C H

ast columns have dealt extensively and can continue to be, successful. why the Federation of Texas Psychiatry Pwith the fact that, as physicians in gen- Past experience reveals proof of that suc- exists. eral and as psychiatrists in particular, we all cess. If not for the efforts of TSPP members In an effort to begin the process of have a duty and a responsibility to take in the past on individual and collective accomplishing these many and worthy J. Clay Sawyer, MD steps necessary to ensure that we offer both bases, non-physicians would even now be goals during the current Texas legislative the best quality of care to our patients and performing psychiatric admissions and session, the Federation is sponsoring our prescribing psychotropic medications. For latest Capitol Day later this month on reasonable access to that care. Maintaining the afternoon for debriefing. the good of our present and future patients, Wednesday, February 28, 2007. The pro- our high educational standards, and con- Complete registration information and we cannot allow that to happen. We must gram will begin at 10 am in the Thompson tinually updating our own theoretical and legislative contact information will have also carry the message of the House of Auditorium of the Texas Medical practical knowledge, meets part of that been mailed to TSPP members, to Academy Medicine regarding other efforts by non- Association Building in Austin at 401 West standard; TSPP’s annual scientific program members, to TSCAP members, and to other physicians to assume physician roles with- 15th Street. We will hear legislative updates is a primary means of achieving that goal. psychiatrists by the time this column out the benefit of proper and complete from Federation and TMA lobbyists as well But further steps are necessary: an active appears in the Texas Psychiatrist, the medical training. All of these messages are as news from other mental health advocacy role in advocating for our profession and Federation newsletter. For now, though, all interrelated and centered on quality patient organization partners. We will then visit for our patients is an effort we should all participants should contact their state rep- care. Performing this mission is one reason with various legislators and reconvene in undertake, an effort at which we have been, resentatives and state senators as soon as possible for appointments between 11 am and 4 pm on the 28th. 2007 Texas Legislature A small fee will be charged for physicians to participate, but residents can attend for continued from page 7 before the Texas Medical Board must pass SB 414, Eddie Lucio Jr. — PHARMA- free and are heartily encouraged to do so. each part of the examination within three CEUTICAL REPORTING: Each year, a White coats are recommended for all physi- United States citizen or an alien lawfully attempts, except that, if the applicant has manufacturer or repackager that sells or cian attendees to maximize impact. Wear admitted for permanent residence in the passed all but one part of the examination repackages prescription drugs in this state them if you have them! United States must present proof satisfac- within three attempts, the applicant may shall submit a report to DSHS that discloses This work is not particularly hard, but it tory to the Texas Medical Board that the take the remaining part of the examination any gift, fee, payment subsidy, or other is necessary. Legislators want to see their applicant has practiced medicine or has one additional time. However, an applicant economic benefit received by a physician, constituents, and they have great respect signed an agreement to practice medicine is considered to have satisfied the require- physician’s office, hospital, nursing home, for busy physicians who take the time and as a condition of the license for at least ments if the applicant: passed all but one pharmacist, health benefit plan admini- three years in an area in this state that is make the effort to go to Austin to see them. part of the examination within three strator or other person authorized by Let’s not disappoint them! designated as a health professional short- attempts and passed the remaining part of law to dispense or prescribe drugs in The Federation speaks with the power of age area or a medically underserved area. the examination within six attempts; is spe- this state in connection with detailing, the voices of the nearly 46,000 physicians SB 36, Jane Nelson — TEXAS MEDICAL cialty board certified; and has completed in promotional or marketing activities who belong to its member organizations. BOARD: An applicant who, on September 1, this state an additional two years of post- of the manufacturer or repackager, Let’s not let this clout go to waste! 2005, held a physician-in-training permit or graduate medical training approved by the directly or through its pharmaceutical I had an application for the permit pending board. marketers. I See you in Austin on the 28th.

FEDERATION OF TEXAS PSYCHIATRY CALENDAR OF MEETINGS The Federation was established on July 1, 2004 with the following purposes: FEBRUARY A. to promote the common professional interests of psychiatrists; 28 CAPITOL DAY B. to facilitate the coordination of and work in concert with state professional psy- Texas Medical Association Building chiatric associations and state professional subspecialty psychiatric associations, 401 West 15th Street to unify programs that advance public and professional education and advocacy for psychiatry and persons with psychiatric illnesses; Austin, Texas 78701 Contact: Debbie Sundberg, 512/478-0605 C. to provide centralized services to state professional psychiatric associations and state professional subspecialty psychiatric associations; APRIL D.to make psychiatric knowledge available to other practitioners of medicine, to sci- entists, and to the public; and, 26-28 TMA TexMed 2007 Hyatt Regency Hotel, Dallas, Texas E. to promote the best interests of patients and those actually or potentially making use of mental health services. 27 TMA SECTION ON PSYCHIATRY PROGRAM 9am-5pm Contact: TMA, 512/370-1300 or www.texmed.org The TEXAS PSYCHIATRIST is published 5 5 e 2 X

times a year in February, April, June, August, g D T 5

T a , . t S D s o

and October. Members of Federation member I N o I T N P T A R

28-29 TSPP COMMITTEE AND EXECUTIVE COUNCIL MEETINGS AND t S . P i organizations are encouraged to submit arti- S S R U m . r P

CME PROGRAM, “Practical Clinical Applications of the CATIE Studies,” A U cles for possible publication. Deadline for e presented by Michael Schwartz, MD submitting copy to the Federation Executive P Adolphus Hotel Office is the first day of the publication Dallas, Texas month. Copy must be edited, acceptable for publication. Contact: Debbie Sundberg, 512/478-0605 Display advertising is available and publica- tion is determined on a case by case basis by JULY the Editorial Board. The Editorial Board 27-29 TSCAP SUMMER CONFERENCE reserves the sole right to accept or reject any “New Directions in Child and Adolescent Psychiatric Treatment” submitted advertising copy. Moody Gardens Hotel EDITORIAL BOARD Galveston, Texas Joseph Castiglioni, Jr., MD

Contact: Debbie Sundberg, 512/478-0605 Edward L. Reilly, MD y r t a i

MANAGING EDITORS h

NOVEMBER c y John R. Bush 5 s 7

2-4 TSPP ANNUAL CONVENTION & SCIENTIFIC PROGRAM 6 P

Debbie Sundberg e t s L Westin Galleria Hotel i a A u I S x

Federation of Texas Psychiatry R Houston, Texas , t e E 1 e T T

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401 West 15th Street, Suite 675 e f A r

Contact: Debbie Sundberg, 512/478-0605 7 t 8 o S Austin, Texas 78701 M

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(512) 478-0605 a E o 5 x i 1 T t

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(512) 478-5223 (FAX) T a

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[email protected] (E-mail) E W t

d s 1 M I u e http://www.txpsych.org (Website) 0 T A F 4

8 TEXAS PSYCHIATRIST FEBRUARY / MARCH 2007