Princess Health and Panel considers involuntary, court-ordered outpatient treatment for mentally ill; foe says would infringe on personal rights. Princessiccia

Princess Health and Panel considers involuntary, court-ordered outpatient treatment for mentally ill; foe says would infringe on personal rights. Princessiccia

behavioral health courts General Assembly legislation legislature mental health mental illness

Gusty 13:19 Add Comment

            Princess Health and  Panel considers involuntary, court-ordered outpatient treatment for mentally ill; foe says would infringe on personal rights. Princessiccia

Representatives from five groups involved in mental health offered legislators solutions June 15 for ending the revolving door between hospitalization, incarceration and homelessness that often exist for those with severe mental-health conditions.

Many who spoke at the three-hour meeting of the  Interim Joint Committee on Health and Welfare said judges should be able to order mentally ill adults who meet strict criteria into an "assisted outpatient treatment" program. Others said that would add costs and a burden to the judicial system, and infringe on personal liberties. But all agreed that the state lacks resources to care for such adults.

Shelia Schuster, executive director of the Kentucky Mental Health Coalition, voiced strong support for the idea. She said its main goal would be to create a narrowly defined program "to access supported outpatient treatment under a court order, again without having to be involuntarily committed or coming through criminal justice system."

Now, a mentally ill person who needs care but does not want it can only be court-ordered into treatment after being released from a hospital or jail.

Various versions of this legislation have have been filed in the General Assembly since 2013. Last year's version, House Bill 94, passed out of the Democrat-led House, but died in the Republican-led Senate. The bills are often referred to as "Tim's Law," named for Tim Morton, a schizophrenic who was hospitalized involuntarily 37 times by his mother because this was the only way she could get him the treatment he needed. Morton died in 2014.

�We do want to make sure that those individuals, like Tim Morton, who are very ill and who are unable to recognize it, who spend much of their lives in the revolving door of hospitalization, homelessness, or incarceration, are afforded a new opportunity to stay in treatment long enough to see the positive effects and the road to recovery,� Schuster said.

Steve Shannon, executive director for the Kentucky Association of Regional Programs, said the state needs assisted outpatient treatment to keep those with mental-health conditions out of the criminal justice system.

"If we can keep a person out of criminal justice involvement, it is better for them, " he said. "Folks have enough challenges already; why add that piece to it? . . . It affects housing, it affect employment."

Shannon also proposed that the state seek a Medicaid waiver to help pay for housing and supported employment for such adults, and a spend-down option to allow the poor on Medicare to also get Medicaid, which offers more services.

Jeff Edwards, division director of Kentucky Protection and Advocacy, who supports does not support Tim's Law said "assertive community treatment" teams are already available to this population, but only on a voluntary basis. He also noted that the ACT program is laden with issues, including geographical access, wait times to get services, and frequent staff turnover.

"Right now, you have to live in one of 56 counties to get the ACT services," he said. "We have to expect quality services, no matter where a person lives in the state."

Ed Monohan of the Department of Public Advocacy, a long-time opponent of the court-ordered treatment model, said  he supports enhancing the ACT teams, which provide a comprehensive array of community supports to this population through individual case managers who are available 24 hours a day.

"Long-term, engagement with clients, with people, is a far superior long-term strategy than coercion through a court system," Monohon said. "The mental-health system, rather than the court system, is the better place to really address this long-term. ... Their liberty is at stake with this coercion."

"I know it is about civil liberties and the rights of individuals, but for them, in the disease process, they have lost the ability sometimes to make those decisions clearly for themselves," said Rep. Addia Wuchner, R-Florence, after sharing deeply personal stories about a family member who had severe mental illness.

During an impassioned plea of support for Tim's Law, Kelly Gunning, director of Advocacy National Alliance on Mental Illness in Lexington, told the story of how her son, while under the care of an ACT team, "brutally assaulted" both her and her husband in January. She emphasized that while the ACT program does offer a "robust array of services," it is based on voluntary compliance.

"They are voluntary. Do you hear me? They are voluntary! If my son doesn't want to open the door for his ACT team, or his doctor who comes to his home, he doesn't have to," she said. "And (as) we were cleaning out his home, we found a years stockpile of medication untouched, untaken because he doesn't believe he has an illness."

Allen Brenzel, clinical director with the state Department for Behavioral Health, Development and Intellectual Disabilities, along with many others at the meeting, acknowledged that a lack of resources is a large part of the problem.

"I mostly hear unity around the issue that we must do better," he said, adding that not only assisted outpatient treatment is needed: "It's going to be the allocation of resources and the moving of resources to appropriate places."

Committee Co-Chair Sen. Julie Raque-Adams, R-Louisville, encouraged the group to examine this issue "holistically" and committed to working on a solution. "Across the board, this is one of those issues that we can no longer stick our heads in the sand and ignore,"' she said.

Princess Health and Doctors trying to reverse course on opioid prescriptions can find it difficult because of addiction, shortage of good alternatives. Princessiccia

Princess Health and Doctors trying to reverse course on opioid prescriptions can find it difficult because of addiction, shortage of good alternatives. Princessiccia

behavioral health chiropractors doctors hospitals marijuana pain management physicians prescription drug abuse prescription drugs

Gusty 08:37 Add Comment

The epidemic of opioid overdoses, 60 percent of which are blamed on abuse or misuse, "is changing prescribing habits, but there's still a lack of other pain medications, access to alternative therapies and knowledge among primary-care providers about multidisciplinary approaches to pain management," Modern Healthcare reports.

"The medical community turned to opioid prescriptions to address a condition many believed had been ignored or undertreated," Steven Ross Johnson writes. "And the dependence on fee-for-service payments also made it easier for providers to whip out their prescription pads rather than spend the time to help patients find alternatives. But experts now say the over-reliance on opioids for chronic pain, despite a lack of evidence on their efficacy and impact, was misguided and has distorted the public's concept of what pain is and what it means to be treated."

But reversing course can be difficult because many patients "have built up resistance to opioids and seek treatment while addicted or at risk of addiction," Johnson reports. He quotes Dr. Neel Mehta, medical director of Weill Cornell Medical College's Pain Medicine Center, which specializes in treating long-term pain as saying many come there because their doctor won't write them another prescription: �So we're sort of left with them expecting to get prescribed an opioid and we have to then calmly redirect that.�

In March the federal Centers for Disease Control and Prevention "recommended doctors prescribe alternative treatments such as over-the-counter medications, cognitive behavioral therapy and exercise before resorting to opioids. Weeks later, the Joint Commission [which accredits health-care facilities] clarified its 2001 standards for pain management and treatment to stress that opioid use was neither required nor specified for treating pain."

Other alternative treatments chiropractic care and the use of anti-inflammatory and neuropathic medications and even vitamin supplements, Johnson notes. "The problem is that few carry the punch or, for some, the pleasure of opioids. . . . The use of medical marijuana, meanwhile, has increased in several parts of the country. It's approved in 38 states and the District of Columbia for patients with illnesses such as cancer and HIV. But only some of those states allow the use of marijuana to relieve chronic pain." Kentucky does not.

Princess Health and Clark County schools to provide mental health services via contract with agency that can bill Medicaid or private insurance. Princessiccia

Princess Health and Clark County schools to provide mental health services via contract with agency that can bill Medicaid or private insurance. Princessiccia

behavioral health children's health education Medicaid mental health schools teenagers teens youth

Gusty 06:22 Add Comment

Facing a surge in behavioral health cases among students, the Clark County Board of Education has contracted with a mental-health agency services for all preschool through high school students in the district.

Mountain Comprehensive Care will place a mental health therapist in every school to address issues immediately, at no cost to the district, Whitney Leggett reports for The Winchester Sun: "In the past three years, the district has seen the number of students in the home-hospital program because of mental-health issues surpass those with physical ailments."

Greg Hollon, director of pupil personnel and support services, told Leggett, �Previously, about 80 percent of home-hospital students were for physical ailments and 20 percent for mental. Fast forward a couple of years later, and that has switched to 65 percent mental, 35 percent physical.�

Hollon said the therapists at each school will help the district stay on top of problems. �This puts someone in the buildings full time to be there to address issues as they occur,� rather than requiring staff to call Mountain or some other agency.

Mountain, based in Prestonsburg, is able to provide the service without charge because it can bill Medicaid or private insurance.

Princess Health and Suicide rates are rising in the U.S.; experts attribute high rate in rural Ky. to poor mental health access, stigma and 'gun culture'. Princessiccia

Princess Health and Suicide rates are rising in the U.S.; experts attribute high rate in rural Ky. to poor mental health access, stigma and 'gun culture'. Princessiccia

behavioral health Centers for Disease Control and Prevention guns health care access mental health research rural health suicide

Gusty 09:11 Add Comment

By Melissa Patrick
Kentucky Health News

After a decade of decline, suicide is becoming more common in the United States, increasing by 24 percent from 1999 through 2014, according to the federal Centers for Disease Control and Prevention.

The CDC report looked at cause-of-death data between 1999 and 2014 and found that suicide rates increased for both males and females in all age groups from 10 to 74.

Graph: CDC Age-adjusted suicide rates by sex

Overall, the suicide rate increased from 10.5 per 100,000 people in 1999 to 13 per 100,000 in 2014, showing a steady 1 percent annual increase through 2006 and a 2 percent annual increase after that.

And while the suicide rates for males continues to be higher than those for females, the report notes that the gender gap is narrowing. Among females, the rate of increase was 45 percent, compared to 16 percent for males.

Suicide rates for middle-aged women aged 45-64 were the highest, in both 1999 (6 per 100,000) and 2014 (9.8 per 100,000), showing a 63 percent increase. In females, the largest increase occurred among girls 10-14 (200 percent), though the actual number of suicides in this group was relatively small, tripling from 0.5 per 100,000 in 1999 to 1.5 in 2014.

For men, suicide rates were highest for those 75 and over, with approximately 39 for every 100,000 men in 2014. However, men 45-64 had the greatest increase among males, increasing from 20.9 per 100,000 in 1999 to 29.7 in 2014, a rise of 43 percent.

In 2014, poisoning (34.1 percent) was the most common method of suicide in females and firearms (55.4 percent) was the most common in males.

The CDC report didn't address why suicides are up, but several studies offer clues about possible reasons among the middle-aged, including a study published in 2015 in the American Journal of Preventive Medicine that found that "job, financial, and legal problems" are most common in adults aged 40-64 who had committed suicide, and a 2011 CDC study which found that suicide rates increased during periods of economic recession and declined during economic growth among people aged 25-64 years.

Rural areas have highest suicide rates

Suicide is the 10th leading cause of death in the nation and the state, and with nearly 700 Kentuckians dying by suicide annually, Kentucky is one of the top 20 states for it.

Suicide is more prevalent in rural areas, where the rate is almost twice as high as in urban areas (17.6 suicides per 100,000 vs. 10.3 per 100,000), according to a separate CDC study.

"The myth is that suicide is an inner-city, urban problem, but the reality is that it is not," Melinda Moore, a licensed psychologist and assistant professor at Eastern Kentucky University, said in a telephone interview.

Moore, also the chair of the Kentucky Suicide Prevention Group, attributed some of the increase in suicide rates in rural Kentucky to its "gun culture."

"We have a culture that is very familiar with guns and that familiarity, unfortunately, can really lead to people using very lethal means when they are suicidal," she said.

And when you add gun culture to economic distress, which is common in much of rural Kentucky, it can be a "cocktail for disaster" for those who are suicidal, she said.

Another challenge is the lack of access to mental-health care in rural Kentucky, Moore said, noting that even if people have access to mental-health providers, many providers aren't trained to work with suicidal people. She said this should be improving, since the state now requires all behavioral health providers get suicide training when they renew their licenses.

Julie Cerel, psychologist and associate professor in the University of Kentucky College of Social Work, attributed the increase in rural suicides to several things, including the Gun culture, lack of access to mental-health care and the stigma that surrounds mental-health issues that deters people from seeking help.

Cerel, also president-elect of the American Association of Suicidology, said one reason for the national increase in suicides could be that coroners have become better trained on how to report them. She said that is very important, because people who were close to a person who died by suicide need to know so that they can seek their own mental-health support.

Cerel said 47 percent of Kentuckians knew someone who died by suicide, "and people who are exposed to suicide, especially if it is someone close to them, are more likely to have their own depression and anxiety and thoughts of suicide."

What should you do if you have suicidal thoughts or are concerned about someone?

Moore and Cerel said the first line of defense, especially in areas that don't have great mental-health resources, is to call the national suicide-prevention lifeline, 800-273-TALK (8255). This is a free, 24/7 service that can provide suicidal persons or those around them with support, information and local resources. It also offers a website at www.suicidepreventionlifeline.org .

Moore said community mental health centers are also great resources for those who are suicidal in rural Kentucky, and Cerel stressed the importance of telling someone if you are having suicidal thoughts, including your primary health-care provider.

Princess Health and Rural drug-overdose rates, high in Kentucky, blamed partly on limits on treatment medication and mental-health services. Princessiccia

Princess Health and Rural drug-overdose rates, high in Kentucky, blamed partly on limits on treatment medication and mental-health services. Princessiccia

Appalachia behavioral health Congress drug abuse drugs health rankings mental health

Gusty 10:55 Add Comment

"People in rural areas of Appalachia are more likely to die early deaths than in other parts of the country," and a big reason is that they "die from drug overdoses at greater rates than the rest of the country," writes Kery Murakami, the Washington, D.C., reporter for Community Newspaper Holdings Inc.'s CNHI News Service.

Murakami notes that in Leslie County, Kentucky, 7.9 of every 10,000 residents overdosed each year in 2012-14. "That�s six times the national rate," and third in the nation, he writes, citing the annual County Health Rankings done for the Robert Wood Johnson Foundation by the University of Wisconsin Population Health Institute. Several other Appalachian counties in Kentucky and West Virginia rank high.

The rates are high partly because "addicts in some parts of the country get turned away by doctors and are not given a drug called buprenorphine that is used to kick opioid addictions," Murakami reports, citing addiction experts. "Buprenorphine causes less euphoria and physical dependence and can ease withdrawal and cravings."

However, "Federal law caps the number of patients to whom a doctor is allowed to prescribe the drug, out of concern of creating places where large numbers of addicts receive opioid-based medication. Such treatment hubs, much like methadone clinics, bring unwanted community opposition, said Mark Parrino, president of the American Association for the Treatment of Opioid Dependence. That limits treatment choices in rural areas, where one doctor might be the only one licensed to prescribe buprenorphine for hundreds of miles."

The Department of Health and Human Services is moving to ease the limits, and Sens. Ed Markey, D-Mass., and Rand Paul, R-Ky., want to go even further. "But some addiction experts are concerned that raising the caps on buprenorphine will nudge the country toward treating addiction with medication rather than counseling, Murakami reports. The department�s proposed rules would require mental-health care, which is often hard to get in rural areas. The senators� bill would not.

�Turning people away from the most evidence-based treatment we have for a chronic, life-threatening disease is heart wrenching for a doctor,� Dr. Kelly Clark, president-elect of the American Society of Addiction Medicine, told CNHI. �Rural areas have been hit hardest by this round in overdoses, which is the worst round of overdose deaths in our country.� She said medication is especially important in rural areas because opioid use spreads among families. �In rural areas, you�re treating the person, their parents and grandparents,� she said. �Entire families are addicted. It�s not like saying, �Stay away from certain friends,� if they�re shooting up with their sister and their mother.�

Princess Health and Bevin gets bill to create third-party appeals process for denied Medicaid claims, which sponsor says are all too common. Princessiccia

Princess Health and Bevin gets bill to create third-party appeals process for denied Medicaid claims, which sponsor says are all too common. Princessiccia

behavioral health doctors General Assembly health insurance hospitals insurance legislation legislature Medicaid physicians

Gusty 16:05 Add Comment

By Melissa Patrick
Kentucky Health News

A bill to create an independent process for Kentucky health-care providers to appeal claims denied by Medicaid managed-care organizations is on its way to the governor's desk for his signature.

Sen. Ralph Alvarado

The only appeals process for providers now is through the MCOs themselves, and the only recourse for denied claims is through the courts.

"We are looking at almost 20 percent of the claims that are out there through Medicaid being denied to providers," the bill's sponsor, Republican Sen. Ralph Alvarado of Winchester, told Kentucky Health News. "So with that there are millions of dollars that all of those providers are losing out on. This finally gives them an opportunity to keep the MCOs accountable."

WellCare of Kentucky, one of the MCOs Alvarado targeted last year while trying to get a similar bill passed, denied that it has so many disputed claims, but says it will work with the Cabinet for Health and Family Services if Senate Bill 20 is enacted.

"WellCare of Kentucky rarely disputes claims for medical necessity, with only 1 percent of claims being denied for this reason," spokesperson Charles Talbert said in an e-mail. "We are supportive of initiatives that help to ensure our members get the right care, at the right time, in the right setting."

Another MCO that Alvarado targeted last year as having a high rate of denied claims, Aetna Better Health of Kentucky, formerly CoventryCares, said in an e-mail, "We work tirelessly, along with our network of providers to improve access to and quality of care for our Medicaid members and we are committed to continuing these valuable collaborations."

CareSource, another MCO, declined to comment.

Kentucky implemented managed care in 2011 mainly as a way to save money. In managed care, an MCO gets a lump sum per patient, a system that encourages them to limit payments to providers. Providers have complained about denied claims and slow payments, causing some to suggest that managed care creates an incentive to deny care.

"Kentucky Medicaid MCOs have a denial rate that is four times the national average," Alvarado said in an e-mail. "These MCOs, in general, are garnering massive profits on the backs of our providers by simply not paying for services; and then claiming that they are 'managing care'."

MCOs serve about 1.1 million Kentuckians and account for about 69 percent of the state's Medicaid budget, according to a state news release.

Last year the state renegotiated all MCO contracts in hopes of decreasing the number of disputes over rejected claims, but health-care providers told the Senate Health and Welfare Committee Jan. 13 that this is still an ongoing problem, especially with behavioral health.

Nina Eisner, CEO of The Ridge Behavioral Health Systems, told the committee that there are examples all over the state of patients with homicidal thoughts unable to get their care paid for by MCOs.

Senate Bill 20 says that after providers exhaust an MCO's internal appeals process for denied claims and a final decision has been made, the provider can then seek a third-party review from an administrative hearing tribunal in the cabinet. The appeals process would apply to all contracts or master agreements entered into or renewed on or after July 1, 2016.

Alvarado said the proposed appeals structure is very similar to the one for commercial insurance appeals at the Department of Insurance. He noted that Kentucky's commercial denial rates are around 6 percent, which are close to the national average, and said he hopes this independent appeals process will bring the MCO denial rates more in line with this.

"If we go from 20 percent to 6 percent, I think most providers will accept that," he said. "This is fair. It is fundamentally American to have an appeals process and it is needed."

Alvarado sponsored a similar bill last year, but it died in the House. A similar bill passed both chambers in 2013, but then-Gov. Steve Beshear vetoed it. Alvarado said he is confident Gov. Matt Bevin will sign this year's version.

Alvarado said that once this "fractured relationship between providers and Medicaid" has been mended "it might actually open up the door for more providers to participate with Medicaid."

Sheila Schuster, a Louisville mental-health advocate, agreed, and said that while Medicaid reimbursement rates are "not great," not being paid at all for services rendered is not acceptable and has been a deterrent for providers to participate.

She said the Kentucky Mental Health Coalition and the National Alliance on Mental Illness support SB 20 because "they want providers to be fairly treated and to be able to provide the services that they need."

Princess Health andStudy suggests that adolescent exposure to alcohol can negatively affect learning, memory and behavior in adulthood.Princessiccia

Princess Health andStudy suggests that adolescent exposure to alcohol can negatively affect learning, memory and behavior in adulthood.Princessiccia

alcohol behavioral health children children's health learning disorders research

Gusty 11:44 Add Comment

A study at Duke University suggests that repeated exposure to alcohol during adolescence causes long-lasting changes in the part of the brain that controls learning and memory. The study, published in the journal Alcoholism: Clinical & Experimental Research, helped explain how exposure to alcohol before the brain has fully developed can cause cellular and synaptic abnormalities and negatively affect behavior. Kentucky is ranked 9th in the nation for the percentage of children who drank alcohol before age 13 (25.1 percent), according to the state Department for Public Health.

"In the eyes of the law, once people reach the age of 18, they are considered adult, but the brain continues to mature and refine all the way into the mid-20s," said lead author Mary-Louise Risher, a post-doctoral researcher in Duke's Department of Psychiatry and Behavioral Sciences. "It's important for young people to know that when they drink heavily during this period of development, there could be changes occurring that have a lasting impact on memory and other cognitive functions.

Studies had shown that animals exposed to alcohol at an early age do not perform as well in memory tasks as those not exposed to it. The new study, which involved exposing young rodents to alcohol and waiting for them to grow into adulthood, found that the exposure also affects the hippocampus, the area of the brain that controls memory and learning. The researchers measured a cellular mechanism called long-term potentiation, which involves the strengthening of brain synapses being used to learn new tasks or bring up memories. Ideally, LTP should be high, especially in young people. The researchers found that the adult rodents exposed to the alcohol during adolescence had higher levels of LTP, which may seem to be a positive outcome but is actually not.

"If you produce too much LTP in one of these circuits, there is a period of time where you can't produce any more," said senior author Scott Swartzwelder, a Duke professor. "The circuit is saturated, and the animal stops learning. For learning to be efficient, your brain needs a delicate balance of excitation and inhibition�too much in either direction, and the circuits do not work optimally."

The researchers also observed a structural change in individual nerve cells: those exposed to alcohol at a young age have brain cells that appear immature, even in adulthood. "It's quite possible that alcohol disrupts the maturation process, which can affect these cognitive functions later on," Risher said. She also noted that the immature appearance of the cells might be associated with behavioral immaturity.

Princess Health andPain and fever reducer acetaminophen, most-used drug in U.S., is found to reduce positive emotions and reduce psychological pain.Princessiccia

Princess Health andPain and fever reducer acetaminophen, most-used drug in U.S., is found to reduce positive emotions and reduce psychological pain.Princessiccia

behavioral health drugs mental health pain pain management pharmaceuticals research

Gusty 19:56 Add Comment

Ohio State University researchers discovered a new side effect of acetaminophen, a leading over-the-counter pain reliever: it also blunts positive emotions. Other research revealed that it helps reduce psychological pain. The drug has been used in the U.S. for more than 70 years and is best known by the brand name Tylenol.

In the Ohio study, participants took Tylenol or a placebo, then looked at very pleasant or very disturbing photos. Those in the experimental group reported weaker emotions than those in the control group. On average, those who took the placebo rated their level of emotion when viewing the photos at 6.76 on a scale of 10, while people who took the pain reliever averaged 5.85.

"Rather than just being a pain reliever, acetaminophen can be seen as an all-purpose emotion reliever," said Geoffrey Durso, the lead author of the study and a doctoral student in social psychology.

Balwin Way, an assistant psychology professor who conducted the study with Durso, said those who took Tylenol didn't seem to be aware they were reacting differently. "Most people probably aren't aware of how their emotions may be impacted when they take acetaminophen," he said.

Acetaminophen, found in more than 600 medicines, is the most common drug in the U.S., according to the Consumer Healthcare Products Association. Every week approximately 52 million American adults, 23 percent of the population, use a medicine with acetaminophen in it. Durso said researchers don't know if other pain relievers like ibuprofen and aspirin have similar effects, but they plan to study that question.