The Americans with Disabilities Act of 1990 (ADA) was to have ushered in a new age of equal opportunity for individuals suffering from physical and mental infirmities. But rather than providing "a clear and comprehensive national mandate for the elimination of discrimination against individuals with disabilities," the ADA often becomes the legal battleground upon which individuals' rights clash with the economic interests of businesses that bear the brunt of the costs associated with equality.
All of the forces affecting and influencing my professional life thunder through my day like these footsteps on the bridge. So many times we hear that private practitioners are "dinosaurs" in today's managed health care environment. At times, I admit, I do feel like a hanger-on in some evolutionary cul-de-sac. Yet, as referrals keep coming in, I find myself feeling more and more fit to survive the Darwinian challenges facing psychiatry. Sharing daily life with colleagues I trust and respect better enables me to live with or ignore the "footsteps on the bridge," which in my more optimistic moments I imagine to be the sound of the real "dinosaurs" rumbling off into the mist.
Prior to training in psychiatry, my practice was in a rural primary care setting where I routinely collaborated closely with physician assistants and nurse practitioners. I see prescriptive privileges of one form or another for psychologists to be an inevitability. I watched a similar struggle for nurse practitioner prescriptive privileges in Oklahoma during my stint in primary care. My recommendations to physicians in California would be to endorse prescriptive privileges for other mental health professionals in the format of the "physician extender" model similar to the traditional physician assistant.
Proponents of SB 694 argue that the doctoral-level training undertaken by psychologists qualifies them to deal with mental illness more so than most physicians. More than 75% of mental health prescriptions are written by general practitioners who have limited training in treating mental illness. They say it makes good sense to set up a system in which psychologists who meet additional educational requirements would be given the authority to prescribe medication. Opponents contend that the training provided for in the bill is inadequate. Many feel that as time brings new and significantly more powerful drugs for the treatment of mental disorders to the market, the arguments against psychologists prescribing will increase.
The role of psychiatry in primary care is an area of rapid expansion and increasing significance. Given the fact that inadequate diagnosis and treatment of psychiatric disorders are major public health problems, it is essential to integrate psychiatrists into multidisciplinary primary care teams. Since primary care physicians are increasingly called upon to act as "gatekeepers" in managed care programs, they will have to meet the important and growing need for broader psychiatric diagnostic and referral skills.
A number of parameters determine how many psychiatrists our nation needs. First is the incidence and prevalence of mental disorders. Second is the kind of clinical care individuals with mental disorders will need, and who will provide that care. Individuals with mental disorders require a thorough diagnostic assessment. Does this need to be provided by a psychiatrist? Obviously, some individuals will need medications as an aspect of their care. These medications must be prescribed by a physician. Does that physician need to be a psychiatrist? Some individuals with mental disorders will need psychotherapy. Does the psychotherapy need to be provided by a psychiatrist?
I find expertise is best defined by the attending psychiatrist. I usually ask them whose opinion they respect in the community, whether that person is acceptable to them to do the evaluation and if their conclusions about disability would be acceptable. If the attendings have no one in mind, I have developed a network of excellent forensic psychiatrists around the country from which I can draw. In this case, I make a suggestion, and ask the attending if the particular provider is acceptable.
My best advice is that whatever you're going to branch out into, it's like Abraham Lincoln said: 'If I had nine hours to chop down a tree, I'd spend eight sharpening my axe.' If you really want to write a novel and use your psychiatric expertise to do that, first really dedicate yourself to learning the structure of a novel. Even if it's something as simple as buying a series of tapes, taking a class or buying a book. Do that before you put pen to paper. And then, actually do the work.
There's such an enormous need, said Renshaw, noting that a study of 100 white, middle-class, well-educated couples revealed that more than 70% of the women and 50% of the men reported they had sexual problems. "Ours is a small clinic, in no way able to meet the demand for treatment or training from all who request it. About 80 couples a year are treated. The waiting list is much too long. Couples wait between three and 10 months to come in for therapy, a far from ideal situation."
An injunction barring further marketing of the generic drug Repronex, recently approved by the Food and Drug Administration, was issued by a U.S. District Court July 25. Although this is the first time that a court has ruled against an FDA determination of generic equivalence in numerous lawsuits brought by manufacturers of reference brand products, it is not the first time that Sporkin has decided against a federal agency. Sporkin wrote, "the FDA cannot selectively choose to reinterpret the FFDCA (Federal Food Drug and Cosmetic Act) and its own implementing regulations in such an arbitrary manner. 'Same' means 'identical,' just as the agency's own regulation say and an agency must follow its own regulations and not arbitrarily reinterpret those regulations."
Myth #1; I don't need computers in my work. Myth # 2: If I wait, things will stabilize and the prices will come down. Myth # 3: I'm too old to begin thinking about computers. Myth # 4: It's easier for men to understand computers than women.
As a result of the decision in Potvin v. Metropolitan Life Insurance Company, physicians will have due process rights to a notice and a hearing before being terminated from health plan panels. As a result, termination without cause provisions in provider contracts will no longer be enforceable, something doctors nationwide have wanted for a long time.
In a long-awaited decision that culminated often anguished public debate and agonizing over moral and ethical concerns, the U.S. Supreme Court in June reversed the opinions handed down by the 2nd and 9th Circuit Courts of Appeal and held unequivocally that there is no constitutional "right to die." The controversy over physician-assisted suicide will now spread, as each of the 50 states becomes a separate battleground. "Throughout the nation, Americans are engaged in an earnest and profound debate about the morality, legality and practicality of physician-assisted suicide," said Chief Justice William H. Rehnquist. "Our holding permits this debate to continue, as it should in a democratic society."
In Kansas v. Hendricks, the Supreme Court upheld by a narrow 5-4 margin a Kansas law that permits the civil commitment of individuals who, due to a "mental abnormality" or "personality disorder," are likely to engage in "predatory acts of sexual violence." Justice Clarence Thomas said the Kansas statute "comports with due process requirements and neither runs afoul of double jeopardy principles nor constitutes an exercise in impermissible ex post facto lawmaking."
Annick Hollister has always loved to paint. Her parents, Hal and Patsy, remember that ever since the age of 3, art was a way for her to express herself when she couldn't convey her feelings in words.
How can the simple act of forgetting become the impetus for a psychiatrist to develop his own series of self-administered psychotherapy computer programs? According to John Greist, M.D., it began when he forgot to ask his patients important information during the interview process. He also became aware that the very way he formed the question would lead to different responses from the patient, depending on the person he was speaking with or their frame of mind.
A colleague recently told me that he is actively treating more than 250 patients at three separate locations. "Do you think I need a computer?" he asked. That is a question many psychiatrists are asking as they see more patients and do an increasing amount of paperwork to maintain the same income they earned with far fewer patients just five years ago.
Computer-Assisted Diagnostic Interview (CADI) uses the computer to assist, enhance and improve Traditional Diagnostic Interview (TDI). CADI was first presented at the APA's annual meeting in 1996. CADI modifies both data collection and data processing. It occupies a place between the less-than-reliable TDI and the reliable but time-consuming structured interview like the Structured Clinical Interview for DSM (SCID).
Many of us have heard the horror stories and seen them reported on the national news wire services: publicly known persons or their family members have their medical records published, names of HIV-positive persons are released, clerks are bribed to deliver the names of patients and their diagnoses, physicians are given free software in return for their lists of patients' names and addresses. It is not that these breaches of confidentiality could not and did not take place with hard copy medical records, it is just that they are so much easier to accomplish now, and can be done in great number and from remote locations, anonymously.
Detoxification from alcohol and drugs can be safely accomplished in outpatient settings. Careful selection of appropriate patients and frequent monitoring are key elements of successful detoxification. The success of outpatients withdrawing from alcohol without serious medical complications and continuing in recovery programs is comparable to success rates of inpatients when there is careful selection of patients, a good triage process and good nursing and medical assessments.
In 1962, fewer than 4 million Americans had ever tried illegal drugs. By 1983, that number had risen to 80 million. Drug use peaked in 1985 and dropped until 1992. Since then, use has been increasing steadily, particularly among teenagers. This increase is partially a result of a trend back toward glorification of drug experimentation and legalization, and also because there's a general resurgence of smoking. Whether it's marijuana, tobacco, opiates or cocaine, it's still smoking.
Because alcohol- and drug-dependent patients tend to develop high rates of symptoms usually associated with common psychiatric syndromes, practitioners often fail to diagnose substance dependence and instead jump to treat more familiar disorders. The risk that such circumstances will occur is understandable given statistics that two of every three alcohol- or drug-dependent individuals meet the criteria for psychiatric disorders and one of every three such individuals meets the criteria for anxiety or depressive disorders.
Given that cannabis (marijuana, hashish, ganja, dagga, etc.) is the most widely used illicit substance in the Western world, it behooves us as physicians to understand as much about it as possible. The cannabinoid receptor is a good starting point in such a pursuit. Marijuana is not a single substance, but a collection of substances or compounds which become 2,000 on pyrolysis. Numbered among the 400 constituents of the plant Cannabis sativa are some 60 cannabinoids.
To understand our fascination with drugs in the first place, we need to ask some basic questions, such as "Why do we like to take poison in small quantities?" The truthful answer is always some variation of "To feel better." How does this come about, and why do we have so much trouble with it?
Despite the public's growing acceptance of addiction as a biopsychosocial disease from which recovery is possible, an ideological chasm persists between psychiatry AA.
Is the rising use of psychotropic medication to treat anxiety and mood disorders incompatible with the psychoanalytic approach? As a psychopharmacologist and psychoanalyst who frequently provides consultation to analysts regarding medication for their patients, Steven P. Roose, M.D., has studied this question and presented his findings and opinions in various scientific papers, books and meetings.
During a career that has spanned four decades and taken him around the globe, Ari Kiev, M.D., J.D., has studied everything from folk psychiatry in Haiti to community psychiatry in England.
The guidance answers the most commonly asked questions about how ADA affects persons with psychiatric disabilities, said EEOC chairman Gilbert F. Casellas. "It provides practical instruction to employers and persons with psychiatric disabilities on their respective rights and responsibilities."
As a result of today's competitive and rapidly changing economic arena, an increasing number of physicians outside academic centers are getting into the business of establishing investigator sites in which to conduct clinical trials for new drugs.
Although recent news portrays general violence as on the decline, the Centers for Disease Control still rank health care providers only one notch below convenience store clerks and taxi drivers at risk for homicide. Mental health personnel are exposed to these ultimate threats in emergency rooms, on home visits, walking through lonely hospital corridors or hotel corridors during conventions, as well as on the street and at home.
