I’ve been keeping up with the exciting new neuroscience developments on the cause (and hopefully treatment) of Alzheimer’s disease. One of the articles that I recently read was from CNET, “The Red Pill of Alzheimer's: Would You Take It?”  The most recent development is that scientists are now able to go beyond your genetic biomarkers for the genetic risks associated with developing Alzheimer's disease – they can now identify whether you will have a slow progression of the disease or a disease that will “spread like wildfire.” The scientific discussion in the article is interesting, but the part that I found most fascinating was the question that this research poses: If this genetic test was available, would you take it?  Would you take the “red pill” and see how far the rabbit hole goes?

If the “red pill” analogy is lost on you, a quick refresher: The red pill/blue pill concept was popularized in the 1999 movie The Matrix. The movie’s premise is that an artificial reality is advanced enough that it is indistinguishable from reality. And in the movie’s beginning, the protagonist (the always-contemplative Keanu Reeves) is presented with a choice—take the red pill, which will free him from “the matrix” and bring him into the real world, or the blue pill, which will allow him to stay contentedly unaware in the artificially constructed reality.  Borrowing from the movie, the terms “blue pill” and “red pill” have become a metaphor for the choice between facing the world’s difficult realities and maintain the blissful ignorance of illusion. 

So, back to Alzheimer’s disease; the real issue is whether or not consumers will avail themselves of these genetic tests. Alzheimer’s disease is really only the beginning—I’m sure that more advanced testing with genetic markers will soon be available for other conditions as well. The ramifications of these tests will take us far beyond medical decisions and treatment options; it is the individual psychological and larger societal implications that will have a monumental impact. Will consumers yearn to know so that they can better manipulate the outcome, choosing to live with the knowledge of their future demise? Or, will they trade in the time that they could gain to prepare for their fate for the bliss of temporary ignorance? 

I think the answer to that question lies in American’s unique “where there’s a will, there’s a way” attitude.  Consumers maintain a belief that, if they have early knowledge and they have access, there will be some treatment, some technology, some breakthrough that will enable them to change the outcome of the disease. And then the problem will become how consumers deal with the outcome once they have chosen to take the “red pill.”

I was surprised to see this headline on the DHHS web site, "Biofeedback Now Seen as 'Regular' Medicine: Computer-assisted treatment has joined mainstream for pain, anxiety and more". But it makes sense. As our knowledge of both the physical nature of behavioral disorders and the behavioral nature of physical disorders has continued to grow, it was inevitable that we would eventually begin to see the 'therapies' overlap.
The emerging group of tech-enabled therapies—both stimulation-based neuromodulation therapies and exercise-based therapies (like biofeedback in the DHHS article)—will help to drive the health management integration that has been held up as the ideal. That said, I think the going will be slower than necessary, mainly because there is a great deal of professional resistance (both in physical medicine and in behavioral health) to embrace the new treatment models.

Ready or not, tech-enabled consumerism continues to morph the relationship between professionals and the consumers they serve. I've written before about both the move to on-line ratings services for health care professionals (RateMDs; RevolutionHealth; Vitals.com; DrScore.com; HealthGrades.com; MDNationwide.org; ConsumerHealthRatings.com; and Rehabio) and the on-line web sites that sell excess professional capacity by the minute (ETherapistsOnline; MyTherapyNet; WebAddictionTreatment.org; and AsktheInternetTherapist.com). These categories of health care marketing organizations represent something akin to American Idol and HOTELS.COM in the health and human market space. Well, the push of technology is taking this one step further—we now have the progeny of when eBay meets health care.

The eBay of health care may soon be PriceDoc.com. The company just received a U.S. patent on its soon-to-be-released system for on-line bidding on health services which will, according to their press release, make "PriceDoc.com the only online site where patients can "make an offer" for healthcare services with verified providers." The initial focus of PriceDoc is consumers who are uninsured, underinsured or seeking elective procedures with provider organizations and professionals who accept cash or credit card payments. (The service categories on their web site include dental, medical, vision, cosmetic, mental health, weight loss, allied health, and alternative health.)

You may think this type of purchasing model couldn't change the health care space. But don't forget eBay, founded in 1995 selling office equipment and plane tickets; had 250,000 transactions in 1996; and by January 1997 the site hosted 2,000,000 auctions. Bottom line? We can’t rule anything out when it comes to which tech trends will shape the sector. Stay tuned.

Regardless of the final direction health care reform legislation will go, comparative effectiveness research (CER) will be a part of it. While many see CER as a vital piece of the puzzle, some in the health care industry are on the fence about its actual value in improving health care as a whole. A New England Journal of Medicine piece I read recently, by Alvin I. Mushlin, M.D., and Hassan Ghomrawi, Ph.D., M.P.H., “Health Care Reform and the Need for Comparative Effectiveness Research” gave four straightforward reasons for how/why CER is both valuable and necessary in our existing system:

1. Findings from CER will provide a buffer against “blind” cost containment.
2. CER can identify preferred therapies, promoting changes in care and outcomes by identifying and validating such treatments. Such research suggests ways for new financial incentives to be applied both safely and effectively.
3. CER should enable innovation in medicine, by creating ‘disincentives’ for the development of “me too” drugs and devices, and by raising expectations and demands for clear evidence of superiority.
4. CER serves as what the authors call the “first line of defense against blind cost containment,” and can serve as a stimulus for the academic medical and public health communities, thus resulting in greater demand and more opportunities for physicians-scientists to get in on the research.

Let’s wait to see how CER fares in the final health reform bill—and if either side stifles the progress in science and service delivery that CER can bring about and that the health care system as a whole desperately needs.

“Antidepressants May Change Your Personality” was the lead story of the recent daily health news update from healthfinder.gov, the U.S. Department of Health and Human Services’ service to provide current health info to the public. My initial reaction was that this isn’t news. (I’m not making any value judgments about whether this is good or bad, by the way.)

The story cites the research of Tony Tang, an adjunct professor of psychology at Northwestern University in Evanston, which found that taking antidepressants may not only help alleviate depression, but could also make you more extraverted and less neurotic. The study, “Personality Change During Depression Treatment: A Placebo-Controlled Trial,” featured in the December 2009 issue of Archives of General Psychiatry, posits that extraversion—often associated with positive emotions—is believed to help protect from depression, while neuroticism—the tendency to experience negative emotions and emotional instability—is thought to contribute to depression.

The study revives some of the work by Peter D. Kramer (author of Listening to Prozac and Against Depression) following the introduction of Prozac (though the premise is certainly extended to all types of antidepressants) about social questions surrounding the benefits and problems of “norming” one’s personality in the name of treatment. Though this question may seem a bit passé, it is a topic that will certainly get more traction as cosmetic neurology and the concept of “normal” wends its way through the mental health field.

For more on this topic, check out:

Is Cosmetic Neurology the Behavioral Health Business of the Future? The Controversy Over Drugs That Build “Mental Muscle”

If your organization is looking at increasing its private pay services, a new study, “Money or Mental Health: The Cost of Alleviating Psychological Distress With Monetary Compensation Versus Psychological Therapy” published in Economics Policy and Law and summarized in Science Daily’s "Psychological Therapy 32 Times More Cost Effective at Increasing Happiness Than Money" provides some powerful ammunition. The study found that four months of therapy increased "happiness" (as defined by the researchers Christopher J. Boyce and Alex M. Wood at the universities of Warwick and Manchester) as much as a $40,000 raise. The researchers concluded that "The research therefore demonstrates that psychological therapy could be 32 times more cost effective at making you happy than simply obtaining more money."

Despite the happy news for psychotherapy practices and the many vagaries of calculating well-being and happiness, the study speaks to the struggle of government policymakers in determining the 'relative value' of funding health services. "The researchers further draw on two striking pieces of independent evidence to illustrate their point—over the last 50 years developed countries have not seen any increases to national happiness in spite of huge economic gains. Mental health on the other hand appears to be deteriorating worldwide. The researchers argue that resources should be directed towards the things that have the best chance of improving the health and happiness of our nations—investment in mental health care by increasing the access and availability of psychological therapy could be a more effective way of improving national well-being than the pursuit of income growth."

These cost-benefit analyses, in health care analyzed through the lens of comparative effectiveness, will become more frequent as we have more data available through inoperable EMRs and there is greater pressure to reduce health care costs.

Don't miss the great piece "Recent Changes in Medicaid Policy and Their Possible Effects on Mental Health Services” by Jeffrey A. Buck, Ph.D., Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, in the November issue of Psychiatric Services. If you were one of the few remaining people in the field who didn't think that Medicaid funding has come to indelibly change public mental health systems—and will continue to do so—this is a great synthesis of the current and future market effects.

On the system side, Dr. Buck identified the following Medicaid-driven system effects that have already occurred:

• A larger role for state Medicaid authorities in state mental health services and a corresponding decline in the role of mental health authorities;


• Service delivery privatization via Medicaid managed care arrangements which privatize many functions previously provided by public entities


• Increased funding for community-based mental health care


• Increased difficulty in using Medicaid funds for areas not clearly defined within the program;


• Increased accountability of individual service providers via the Medicaid Integrity Program


• Movement away from incentivizing psychiatric institutionalization
  

Dr. Buck also looks ahead to future policy changes. A few are ‘more of the same’—an increase in the role of Medicaid authorities and the growth of community-based services, with continued promotion of deinstitutionalization. In addition, he points to two other developments that are on the horizon. The first is increasing convergence of mental health policy with those that are the norm in primary care. The second is more meaningful consumer participation in treatment plan participation and choice of professionals and provider organizations.

I read not long ago that the State of Georgia is sending released sex offenders to live in a camp in the woods near Marietta, Georgia—even those who own their own homes. There are a myriad of factors that have lead to this situation—zoning laws, parole requirements necessitating these individuals to stay a certain distance from children, and lack of suitable housing (the Associated Press reported that "there is only one homeless shelter in Georgia that fulfils the residency requirements for sex offenders, but it only has two beds, which are usually occupied."). I don't think it's acceptable for our leaders to throw up their hands about the inevitability of this situation, as if they were powerless to effect change.

I find this to be part of a troubling change in our view of the acceptability of treating ‘undesirable’ fellow citizens inhumanely. I think this change in thinking is a threat—a slippery slope in the floor of acceptable treatment—for the consumers we serve. One day it's okay to send people to jail because they have no mental health treatment (they need to exhibit some self control and not act in ways that will land them in jail); the next day it's acceptable to close critical health care services that will result in the death of uninsured persons (who should work hard enough to have insurance); and then we can sentence people (dastardly people who prey on children) to living in encampments without even the human supports of leper colonies of old.

In the behavioral health and social service niche, we serve and advocate for a group of individuals unattractive in popular culture. Runaway teens living on the streets, drug addicts, "the retarded", and more. I caution us all to not stand by when this growing acceptance of inhumanity occurs. For those of you who are not swayed by dewy-eyed humanitarian thinking, you can ponder the immortal words of Ronald Reagan who said, "Protecting the rights of even the least individual among us is basically the only excuse the government has for even existing…”

On the board of directors of a health or social service organization? If so, Atlanta’s Grady Memorial Hospital situation is a cautionary tale. A court ruled on September 25th that Grady Memorial—Atlanta's safety net hospital—could close its outpatient dialysis unit. What brought the Grady management team to the place where courts are ruling on its service lines? Consumer desperation, of course.

Grady accepts all patients despite immigration status or ability to pay, and is the ‘last resort’ provider for many uninsured, according to a recent New York Times article. Unfortunately, Grady’s dialysis clinic was projected to lose $2 million this year, and continuing dialysis services was deemed unfeasible. This prompted a lawsuit asking for consumer relief.

The patients’ lawyer, Lindsay R. Jones, called the order Friday by Judge Ural D. Glanville “an angry, punitive decision.” “At least 51 patients had their life support system unplugged today under the authorization of this judge,” Mr. Jones said. In response to the decision, Grady has agreed to pay for up to three months of dialysis at private clinics for the 51 displaced patients. However, the clinic will still close.

The Grady situation is just the first of hundreds of similar situations we are likely to see. The combination of state and local budget deficits—coupled with a likely new range of payer-level health care cost containment measures—will increase pressure on non-profit provider organizations to continue unfunded services.

And don't expect relief from the courts. One quote from Judge Glanville says it all: “As it relates to the receipt of medical treatment, the court is unpersuaded [sic] at this time that plaintiffs have a constitutional right to the sought-after relief."

Word of advice: Understand the cost structure for each service you deliver. Be proactive in seeking additional funding where needed—or in closing those programs you can't afford to continue.

Have you heard of FleaHab? It's a new exercise-based recovery program track at the Providence Recovery Center in Santa Cruz, California, run by Darryl “Flea” Virostko, a big wave surfer and three-time Mavericks champion. Now, before you get too cynical about this as another addiction treatment gimmick combining a 'tangential' but attractive consumer activity with the market cache of a noted sports figure, consider the emerging science.

Mr. Virostko hopes that FleaHab will be his anchor in the dry terrain of sobriety. Addicts in the program will replace the high of drugs with the endorphin rush of strenuous physical activity, he says. He recently took a group surfing to try his hand at teaching. “It’s like I’m learning to surf again,” he said. “Seeing them so excited reminds me of when I first started...” according to a quote in "Surfing as Rehab for Those Fighting Addiction".

As you may remember from some of my OPEN MINDS live reporting earlier this summer, I spent a fabulous week at the "State of Mind" conference held at the Chautauqua Institution, where we explored "the techniques and current research findings related to mental health disorders and brain injury..." One big takeaway was learning that there is only one way to generate new brain cells—through extreme physical exercise—and to 'turn them on' requires extreme mental challenges. Another interesting takeaway was that almost all psychotropic medications perform better for consumers when combined with an exercise program. These findings are all the more relevant for consumers who can now use new brain scanning technology to watch their brain change as they recover from mental illness, progress in recovery from their addiction, or work to improve cognitive functioning.

I left my week in New York with some distinct thoughts about the future of behavioral health treatment programs. In a decade, it will likely be considered malpractice to provide behavioral health treatment without a rigorous exercise program. And, the programs that provide consumers access to the technologies that allow them to 'see' their brain recovery are the programs that consumers will select. To that extent, FleaHab is on the right path.

Advocates and provider organization management teams are all tracking state budget problems and what they mean for mental health. A few of my colleagues are breathing a sigh of relief because their state budgets left them 'relatively' unscathed. But, for behavioral health and social services, I think the worst budget cuts are yet to come. In 2010, we will have to deal with the effect of the planned state budgets—and probably some mid-year revisions. But, in many jurisdictions, provider organizations will see county and city budgets for these services unravel. On Saturday, ABC news in El Paso, Texas reported that of the El Paso City Council members, four voted to cut ties with the El Paso Mental Health and Mental Retardation agency. Their rationale is that, by law, those services are the responsibility of the county—not the city. ABC-7 reporter Daniel Marin wrote:

"El Paso City Representative Beto O'Rourke says, by law, MHMR is the responsibility of the county. So he along with special city council committee
members… voted to cut ties with the agency…O'Rourke says MHMR's highly publicized funding issues are the result of the old cliché: too many chefs in the mental health care kitchen…"

"MHMR spokesman Rene Hurtado says while every little bit of funding helps, this is all about more than losing the city's $100,000 yearly contribution. "The mental health care system is very complex," said Hurtado. "The more people we have at the table, the better it is for everyone."

"El Paso County Commissioner Anna Perez says, in her opinion, the city has a direct role in helping the city's mentally ill; adding there's too much at stake for city officials to hide behind a law. "[The law] doesn't mean they don't have a place at the table," she said.

The unfortunate reality? Our current systems for mental health treatment, for addiction treatment, for child welfare, and for other social services are strung together with a hodgepodge of federal, state, county, local, grant, donation, and payer dollars. From my perspective, parity and universal coverage can't come too soon. I'll look forward to a time when Americans with behavioral disorders and disabilities are not begging for safety net funding and charitable donations.

August 21, 2009

In the sea of press releases that I read every day, very few settle into my grey matter. But, today, there was a flash of something happening—though it's a bit early to tell what. The first piece that passed my desk was notice of the first inpatient treatment program for Internet addiction. Just opened outside of Seattle, the reSTART Internet Addiction Recovery Program will help people unplug from the wired world for 45 days for $15,000 (check out their site).

There is nothing particularly new about specialty addiction treatment programs—a quick search of the OPEN MINDS archives and you will find treatment programs for addictions to sex, gambling, shopping, and host of other activities. But, only a few minutes later I was watching a YouTube video from Sony's viral on-line marketing campaign for ending social media addiction. (I was also signing up to learn more about the Social Media Addicts Association.) Trend or data point in the addiction treatment world? Too early to tell.