March
23, 2006
BUDGET:
MENTAL HYGIENE TABLE CLOSED, BUT HEALTH AND MEDICAID TABLE REMAINS
OPEN – CALLS NEEDED!
As
was reported in yesterday’s Update, the Legislature’s
Mental Hygiene Sub-Committee in the Conference Committee process
closed down yesterday, finalizing agreements between the two houses
on all but one major issue – the civil commitment of sexual
offenders in Pharsalia, NY.
By
all indications, the Health and Education Sub-Committees are not
having as much success in achieving agreement, which means that
we still have the opportunity to influence the process on the
issues being discussed at that table. Those issues are:
Medicaid
wrap around for dual eligibles having difficulty accessing drugs
via Medicare Part D plans;
Elimination of a safeguard in the Medicaid program’s Preferred
Drug Program that provides physician with the final say as to
which medication a Medicaid patient will receive;
Allowing the cost of a drug to be used in determining which drugs
will be made available in the Preferred Drug Program, and;
The proposed elimination of the word “care” from the
law, which would undermine a court settlement agreed to in the
Brad H. litigation brought against NYC - this ensures that inmates
released from the criminal justice system have access to the necessary
services provided by Medicaid and other programs.
CALL-IN
TO PROTECT MEDICAID RECIPIENTS:
Please
contact the following Senators to voice your:
-
Support
for the Medicaid wrap around for dual eligibles,
-
Opposition
to the elimination of the safeguards in Medicaid’s Preferred
Drug Program, and
-
Opposition
to the proposal to the Governor’s budget, which would
no longer require people coming out of the criminal justice
system to be provided with Medicaid and other services, which
provide for successful transitions into the community.
Senate
Majority Leader Joseph Bruno at (518) 455-3191
Senate Finance Committee Chair Owen Johnson at (518) 455-3411
Senate Health Chair Senator Kemp Hannon at (518) 455-2200
Your Senator – Call (518) 455-2800 and ask for your Senator
NMHA
LEGISLATIVE ALERT ON LEGISLATION THAT WOULD UNDERMINE TIMOTHY’S
LAW:
Major
Health-Insurance Deregulation Bill Going to Senate Floor
Grassroots Action Needed on Bill
Overriding State Parity, Consumer Laws
Summary
With a key Senate Committee having approved sweeping legislation
that would override state insurance mandates (including state
mental health parity and other laws that protect people with chronic
illnesses), a grassroots outcry is needed to defeat S. 1955, a
bill being falsely marketed as a solution for uninsured Americans.
Background
The Senate Health, Education, Labor and Pensions (HELP) Committee
last week approved on a party-line vote the so-called “Health
Insurance Marketplace Modernization and Affordability Act,”
(S.1955), a bill that would override over 1,000 longstanding,
vital state consumer-protection laws (including mental health
parity laws) that now regulate the individual, small-group and
large-group health insurance markets.
Under
this measure, an insurer would have to offer only one—shockingly
inadequate—alternative to a “bare-bones” insurance
plan. It would have to offer a plan resembling ANY option available
to state employees in one of the five largest states. But that
option may be grossly inadequate, given the variability among
those states' employee-benefit plans. Many of these state employee
plans offer very limited coverage and do not provide mental health
parity. As a result, beneficiaries who now have strong protections
could find themselves with little to no mental health benefits.
Small
employers have a true health insurance affordability crisis. But
S.1955 could actually make insurance MORE expensive for many—particularly
for people with more than minimal healthcare needs. In seeking
to provide for lower-cost health insurance, the bill would fail
those most in need of good coverage. It would do so by weakening
the fundamental protection that insurance provides, that of “pooling”
risk. Various state laws currently prohibit insurers from discriminating
on the basis of age, gender or health status in setting insurance
premium rates. But S. 1955 would override those laws and allow
insurers to set far higher rates for those who are older and sicker,
thereby driving up costs for those with the greatest needs. To
illustrate the problem, when New Hampshire threw out its protections
regarding premium costs and adopted the policy proposed in S.1955,
premiums rose for 80% of small employers in the state.
Status
The Senate HELP Committee approved S.1955 on a party-line vote
after an extremely contentious two-day session. S.1955 may now
be considered by the full Senate as soon as March 27.
Action
Needed:
Most Senators are not yet aware of the sweeping, extremely harmful
provisions in S.1955. Senators need to hear from constituents
before this dangerous legislation is brought before the full Senate.
NMHA urges you to:
-
-
Contact
your Governor and urge the Governor's office to oppose S.
1955 and convey that opposition to the Senate
.
Key
Messages:
-
S.1955
would allow insurance companies to completely circumvent state
mental health parity laws and over 1,000 other state consumer
protection laws.
-
S.1955
would override current state laws that prohibit insurers from
discriminating against individuals based on health status,
geography, age and gender—exposing vulnerable people
to exorbitant premiums.
-
S.
1955 fails to protect those with the greatest health needs.
It proposes an altogether ineffective “solution”
in requiring only that an insurer offer a health-plan option
similar to any plan available to state employees in one of
the five largest states. This “solution” is totally
inadequate, as there are many very limited health plans (including
plans that do not provide mental health parity) available
to those state employees, to include high-deductible plans
with very few benefits. Further, by siphoning healthier individuals
into bare-bones plans, S.1955 would make any more comprehensive
plan unaffordable.
MHANYS
ANNUAL AWARDS 2006 – CALL FOR NOMINATIONS:
Once again, MHANYS seeks nominations for a number of awards to
be handed out later this year at MHANYS Annual Awards Ceremony
on October 26, 2006.
We
are seeking nominations for the following awards:
-
Esther
Mallach Staff Leadership Award
-
Mental
Health Media Awards
-
Parent
Advocate of the Year Award
-
Ken
Steele Memorial Award for Program Excellence
-
Volunteer
of the Year in Programs & Volunteer of the Year in Community
Service
All
nominations must be submitted by Friday, June 16, 2006
For
additional
information and award nomination forms, please go to http://mhanys.org/foraffiliates/awards/index.htm
or contact Helen Weltin at (518) 434-0439 ext. 216 or email infocenter@mhanys.org.
MHANYS'
COMMUNITY MENTAL HEALTH PROMOTION PROJECT HOLDS STATEWIDE TRAINING:
March 13th and 14th marked the 12th annual statewide training
for the teams of the Community Mental Health Promotion Project.
This project is one of two anti-discrimination and anti-stigma
projects run by MHANYS.
Each
year, teams of 5 from each participating MHA affiliate arrive
from all over the state to participate in training. The training
is combined with MHANYS' Legislative Day in order to give the
teams the opportunity to sharpen their advocacy skills as well
as to acquire project development skills, all as part of the same
trip. This year, 10 teams attended the events. After a couple
of hours' rest from running around the Legislative Office Building
and meeting with their elected representatives, teams reassembled
for dinner and an inspirational presentation by the Chair of the
Commission on Quality of Care and Advocacy for Persons with Disabilities,
Gary O’Brien. Chairman O’Brien’s topic, "Using
Advocacy to Fight Stigma and Discrimination,” evoked a lively
discussion.
The
following day, training resumed early with an entertaining and
very informative presentation entitled, "Grant Seeking on
the Internet" by Susan Kemp of the Office of Children and
Family Services. Next, Renee Carr of MHA in Fulton/Montgomery
Counties gave a presentation on "Outcome-Based Planning,"
which helped teams more fully understand how to identify and measure
outcomes for their projects. Finally, each team shared their work
from 2005 and entertained questions from the group. This type
of sharing has long been everyone's favorite part of the day since
we all become so inspired by the terrific work each team is doing
and how much they have accomplished with limited resources.
We
are already beginning to make plans for the 13th Annual Statewide
Training which will take place in March, 2007.
IN
THE NEWS:
No
deals yet as budget deadline looms. By Jay Gallagher
Journal News, March 23, 2006
ALBANY
— With the deadline for passing a state budget on time looming,
lawmakers admitted yesterday that they still don't have agreements
on the biggest questions: how much the state has to spend, what
tax cuts will be approved or how much money will be allocated
to education.
"We
can't give you a number with precision on how much we're going
to spend," Assembly Speaker Sheldon Silver, D-Manhattan,
told reporters after key lawmakers met to discuss budget issues.
"There
are a lot of issues still outstanding," said Senate Majority
Leader Joseph Bruno, R-Brunswick, Rensselaer County.
Lawmakers
want to pass a budget by April 1 to avoid being late for the 21st
time in 22 years. They broke a 20-year string of late budgets
last year, and meeting the deadline has taken on strong symbolic
importance for the competence of the Legislature. All 212 seats
are up for election this fall.
Although
the deadline isn't until midnight a week from Friday, Silver and
Bruno said that, practically speaking, they need a deal by tonight
or tomorrow morning at the latest. That will allow them to print
bills, have them "age" for three days as required by
the state Constitution, then be debated and passed next week.
But
even after the two houses agree between themselves, they still
have to strike a deal with Gov. George Pataki, who has consistently
said that lawmakers want to spend too much and that their plans
will lead to huge deficits two to three years from now.
"Some
progress is being made, but obviously I am concerned about the
magnitude of the spending and the impact on the future years'
budgets as well as the policies that I have advanced," Pataki
said yesterday.
Pataki
proposed spending $110.6 billion next year, a hike of 6.5 percent
in state-supported spending. The Senate wants to spend $111.8
billion and the Assembly $112.4 billion.
All
sides want property tax cuts, but they structure them differently.
Pataki also wants to reinstate a sales tax on clothing worth less
than $110, while the Assembly wants to eliminate it.
Pataki
has proposed hiking education aid by $634 million to a total of
$16.9 billion. The Assembly wants the increase to be twice what
Pataki has proposed, and the Senate would add about $500 million
more than the governor wants.
Subgroups
of lawmakers have continued to meet to try to reach agreements
on specific budget issues, but the education panel hasn't convened
yet.
That's
because there isn't yet any agreement on how much money to spend
on schools, said Senate Education Committee Chairman Stephen Saland,
R-Poughkeepsie.
"There's
no table target, and I can find better ways to spend my time,"
he said. "I think there are other issues that have become
intertwined. I can't find a reason to conduct a meeting without
a table target." He acknowledged that time is short to make
the deadline.
Another
group of lawmakers debating whether the state should set aside
$130 million to build new facilities to house violent sexual predators
who have completed their prison sentences gave up yesterday, dumping
the issue back in the laps of legislative leaders.
"We
can't come to an agreement," Senate Mental Health Committee
Chairman Thomas Morahan, R-New City, told Bruno, Silver and other
top lawmakers.
The
money needs to be allocated now so the state can begin to prepare
facilities to assure the predators are confined, said Assembly
Minority Leader James Tedisco, R-Schenectady.
But
Silver said the budget will include $30 million in operating funds,
which is enough to take care of dangerous predators scheduled
for release for the next few years.
Legislature
rejects converting Pharsalia. By John Milgrim
Oneonta Daily Star, March 22, 2006
Agrees
to keep prison camp open, not change it to sex-offender facility
ALBANY
— Chenango County’s Camp Pharsalia will stay open
at least another year as a minimum-security prison under an agreement
reached by both houses of the state Legislature.
The
Republican-controlled Senate and Democrat-controlled Assembly
rejected Gov. George Pataki’s proposal to close the camp
next month and convert it into the state’s secure facility
for sexual predators.
Both
houses cited state law requiring corrections officers be given
at least a year’s notice before a prison can be closed.
"We’ve
only decided to go along with continuing an appropriation for
the operation of Pharsalia as a correctional facility," said
Assemblyman Joe Lentol, co-chairman of the legislative budget
subcommittee on pubic protection. "Neither the Senate nor
we agree with the executive’s conversion of that facility
without the proper notification that we set up in the budget last
year.
"It
will be open for a year, no matter what happens, as a correctional
institution," Lentol said.
Pataki’s
proposed 2006-2007 state spending plan called for the closure
of Camp Pharsalia on April 1 and its $130 million conversion into
a 500-bed facility for "civilly-confined" sex offenders
by 2009. The move was contingent upon the Legislature agreeing
on laws allowing for the confinement of sexual predators after
their prison sentences are complete.
Obviously, that’s a discussion we’re going to continue
after the budget," said Senate spokesman Mark Hansen. "At
this time, the facility is going to stay as it is, and we will
continue the discussions on civil commitment."
The
Legislature agreed to keep more than $5.2 million in the budget
to continue camp operations as they are now.
Under
Pataki’s proposal, the 258-bed Camp Pharsalia was to have
been demolished and replaced with a secure facility with more
than 1,000 employees and an $80 million annual payroll. The facility
would be operated by the state Office of Mental Health.
The
governor has been trying to close the camp and other prison facilities
for two years to reflect the decline in the state’s prison
population, which has dropped from a peak of nearly 72,000 six
years ago to fewer than 63,000.
While
the door remains open to convert the camp next year, Pataki is
set to leave office Dec. 31. That will likely leave it to the
next governor to decide whether the conversion plan should go
forward.
Catholics
lobby for Timothy’s Law and Rockefeller drug law reform.
By Kelly Smith
Legislative Gazette, March 20, 2006
Father
Jim Goode will never forget the day, standing on 36th street in
Brooklyn, that a dejected woman with two children looked at him
and said: “If only somebody cared.”
She
was poor and had come to receive a donation of clothing, which
he was passing out. He was taken aback by her comment. He reached
out his arms and said, “I care.” Then he embraced
her, her two children, and another man standing nearby.
It
is that spirit of caring for others, he said, that creates a Catholic’s
social consciousness.
Goode
was the keynote speaker at the New York State Catholic Conference’s
public policy forum, “Restoring the Covenant: Keeping Society’s
Pledge to the Poor, the Vulnerable and the Voiceless,” held
last Tuesday at the Empire State Plaza Convention Center in Albany.
“We’re
here as peacemakers. We’re here as people who aren’t
afraid to let our voices be heard in the Assembly,” said
Goode, president of the National Black Catholic Apostolate for
Life.
They
were also there as lobbyists. Many of those attending the forum
met with their representatives in the Assembly and Senate to discuss
the Conference’s top issues, including mental health parity,
Rockefeller drug law reform and education tax credits.
Goode
said members of the Church have a responsibility to try to influence
policy.
“She
[the church] cannot, and must not, replace the state. Yet, at
the same time, she cannot, and must not, sit on the sidelines
in the fight for justice,” he said.
Members
of the Conference lobbied for numerous bills, including:
-
Timothy’s
Law (A.2912-a/S.6735-a), which would require all insurance
policies that offer health coverage to equally cover mental
health and addiction-related issues.
-
Bill
S.1939-a/A.8203-a, which would give parents with children
in school, whether public or private, a refundable tax credit
of $1,100 to $3,500 per child, depending on family income.
-
Bills
A.644/S.2880, which would provide a drug treatment alternative
to incarceration for certain offenders, and A.6796, which
would repeal the mandatory sentencing requirements of the
Rockefeller drug laws.
“This
is just the beginning of the conversation,” said Goode.
“And
it’s up to us to go back to our cities and towns and villages
and continue that conversation with our elected officials.”
N.Y.
advocates encouraged by Assembly passage of Timothy’s Law.
Mental Health Weekly, March 20, 2006
The
New York State Assembly earlier this month passed Timothy’s
Law, the state’s mental health parity bill, revving up hope
among advocates that this year the bill will become law.
Although
a mental health parity bill was introduced in the Senate last
week by Sen. Thomas Libous (R–N.Y.), no further action has
been taken, according to advocates. They vow to press forward
until New York joins 35 other states across the country that have
passed parity laws.
Timothy’s
Law is aimed at ending insurance discrimination against individuals
with mental health and addiction issues. The legislation is named
after Timothy O’ Claire, who committed suicide five years
ago just before his 13th birthday.
The
Senate bill is a very narrow bill, Paige Pierce, executive director
of Families Together in New York State, told MHW. Pierce said
she is pleased the Assembly passed Timothy’s Law, but expressed
disappointment over the Senate bill. “The Senate version
still does not meet the needs of New York State,” she said.
Pierce
added, “We’ve been through so much work trying to
enlighten people about the need for insurance, and the cost savings
and benefit to society.”
The
Senate version does not come close to the definition of parity
in Webster’s dictionary, said Pierce. She noted that this
year is the fifth anniversary of Timothy’s death. “He
would have graduated from high school and would have turned 18,”
said Pierce.
Pierce
is also co-chair of the Timothy’s Law Campaign, a grassroots
effort aimed to end discriminatory practices by health insurers
and health maintenance organizations regarding the treatment of
mental illness and substance use disorder.
Advocates
meanwhile are encouraged by the Assembly’s continued support
of Timothy’s Law. “We’re very excited that Timothy’s
law passed in the Assembly,” Glen Liebman, chief executive
of the Mental Health Association in New York State (MHANYS), told
MHW. “We’re cautiously optimistic that there will
be recognition in the Senate.”
“We
just have to get away from politics and focus on the lives that
could be saved and enhanced by having Timothy’s Law in place,”
said Liebman.
“We
think the Assembly bill is a strong bill,” he added. “Hopefully
both sides will get together. This stalemate has got to end. We’ve
been fighting for a parity bill for over a decade. All sides are
frustrated.”
Liebman
said advocates will continue to press on for the passage of Timothy’s
Law. “We intend on putting grassroots pressure out there,”
Liebman said. “We have several rallies planned and MHANYS
members will also be meeting in the district with their legislative
representatives he said.
Liebman
said he hopes there are no more delays. “At the end of the
day, hundreds of thousands of New Yorkers are impacted. They need
insurance.”
NAMI
encouraged
“Advocates
are thrilled the bill passed the Assembly again,” J. David
Seay, executive director of the National Alliance on Mental Illness
(NAMI)-New York, told MHW. The bill passed by a larger margin
in the Assembly, the first time that has ever happened, said Seay.
Last
year the Senate passed its version of the bill but it was a “weak,
watered-down version,” that didn’t have Timothy’s
name on it, he said.
“It’s
a shame that the Empire State is one of 15 states that does not
have some sort of parity bill,” he said. “Maybe a
conference committee would work out the differences,” he
said.
NAMI
and Timothy’s Law campaign will continue to organize grassroots
efforts, he said. “We’re still working as hard as
we can. We will not stop until it’s passed.”
'Prisoner'
of Part D. By Ridgely Ochs
Newsday (Long Island), March 17, 2006
Since
the Medicare plan began on Jan. 1, prescription costs and availability
is causing a pain in many wallets
Medicare
Part D, the federal government's new prescription drug plan, has
forever changed the way Roxanne Marek and her pharmacist, Bruce
Scheinson, do business together.
For
the past five years, Marek, of Medford, has gone to the drug store
Scheinson co-owns, Centereach Pharmacy and Surgical, to get her
prescriptions filled. She likes the accommodating atmosphere there
and even calls the place "Cheers," after the friendly
bar from the TV show. It's where she has picked up her 30 prescriptions
for various ailments, including chronic back pain, lupus and depression.
That
all changed on Jan. 1, when the government automatically enrolled
her in a new, privately run drug plan. The new plan said she had
to switch three of her drugs, won't cover two more and charged
her a co-pay of $91.50 for another prescription. But the bigger
problem for her are all the new co-pays. Although most are just
$1 to $3 each, Marek lives on just $710 a month from Supplemental
Security Income payments.
Stretched
thin by the drug costs, last month she passed on paying her electric
bill and isn't sure she can afford the insurance for her car.
Scheinson
has problems of his own under Medicare Part D, which was intended
to give more seniors drug coverage. He said he has lost more than
$50,000 since Jan. 1 because of lower reimbursements under Part
D or from co-pays he waived initially because many of his patients,
like Marek, couldn't afford them. And he spends far more hours
then ever on the phone negotiating with the drug providers. One
recent Monday morning, he was trying to help a disabled patient
obtain a long-prescribed drug that was no longer covered by the
man's new plan.
"This
is not a discussion of health," he said as the clock showed
he had been on hold 27 minutes. "This is just trying to get
a prescription filled to put in his hand."
The
cases of Marek, the patient, and Scheinson, the pharmacist, are
not unusual. For many of the nation's 6 million so-called "dual
eligibles" - people such as Marek who were on Medicaid and
Medicare - the move to Medicare Part D has been especially rough.
And after Jan. 1, many pharmacists were scrambling as patients
showed up with little or no information about which of the many
plans under Medicare Part D they had been placed in, discovered
that their plan did not cover their drugs, or found they couldn't
afford their co-pays.
As
a result, 37 states - including New York - have provided temporary
emergency drug coverage. In New York last month, the legislature
overrode Gov. George Pataki's veto and voted to pay pharmacists
Medicaid money until the Medicare Part D problems have been resolved.
But
Craig Burridge, head of the Pharmacists Society of the State of
New York, said pharmacists are still feeling the effects. Many
have had to borrow money to stock their shelves or have laid off
staff, he said. That's because many drug plans have been slower
to reimburse than Medicaid. And, he said, the reimbursements from
drug plans are down 50 percent compared with Medicaid.
"A
lot of them are still in shock," he said of the pharmacists.
In
many cases, Scheinson said, he is no longer able to eke out even
a small profit. He cited an experience with the antihistamine
Zyrtec. He was reimbursed $3.43 for the prescription by the drug
plan, he said. But the customer couldn't afford the $3 copay,
he said "and then I had to deliver it."
Peter
Ashkenaz, a spokesman for the federal Centers for Medicare and
Medicaid Services, said his agency will hold a public meeting
next month to hear comments about a proposal to have the private
plans offer financial incentives to pharmacists who prescribe
less expensive generic drugs.
Medicare
is also considering billing changes to reduce pharmacists' costs
related to filing Medicare claims. He said state Medicaid programs
appeared to have long been overpaying pharmacists for drug claims
- the reason why payments from insurers are lower than payments
pharmacists previously received for dual eligibles.
And
Dominick Washington, a spokesman for the health plan conglomerate
United HealthCare of Minnetonka, Minn., which recently purchased
Marek's drug plan, said some dual eligibles, accustomed to Medicaid,
may not be familiar with limits typical to for-profit managed
care. He would not comment on Marek's case, though he said the
company had "reached out" to her.
But
Marek's neurologist, Dr. Charles Argoff, director of Cohn Pain
Management Center, part of the North Shore-Long Island Jewish
Health System, shares Scheinson's frustration. Marek had been
on the muscle relaxant metaxalone for years, Argoff said. But
her new drug plan wouldn't pay for that drug. Argoff's staff spent
six or seven hours on the phone with the new plan's representative,
but Marek was still put on baclofen, which has only been approved
in the U.S. for use as an antispastic, not a muscle relaxant.
He called Medicare Part D "a joke."
He
said the plan is adding to the marginalization of the poorest
and frailest. "They are creating a disincentive to deal with
these patients. I love my patients, but in reality you can't do
this for everyone," Argoff said, speaking of the hours on
the phone trying to get medications switched.
Scheinson
has already faced the same dilemma. There came a time when Centereach
Pharmacy and Surgical could no longer waive Marek's co-pays. She
says she understood.
Since
then, she has been in despair.
"I'm
not being melodramatic or anything but if lose the car, I basically
become a prisoner," she said. "I am trying to fight
this, but there may come a point when the quality of life becomes
so poor, suicide would definitely be an option."
Study
offers hope to fight depression. By Marilynn Marchione
Albany Times Union, March 23, 2006
Many
patients who get no relief from one drug recover after using second
medication
Many
depressed patients who didn't get better on one medicine were
able to overcome their crushing dark spells with another, according
to the largest study ever of treatments for America's top mental
health problem.
Up
to one-third of those who added or changed medicines recovered.
When viewed with earlier results, the new findings mean that roughly
half of the people who suffer from serious, long-term depression
can get over it -- not just improve their symptoms -- with adequate
medication.
"The
goal here was to find treatments that help people to get well,
not just better," said Dr. Thomas Insel, director of the
National Institute of Mental Health. "We have safe and effective
treatments."
The
agency funded the $35 million study, which involved thousands
of people across the United States and has been widely praised
as a real-world test of five drugs.
The
study found little difference among the drugs tested -- Celexa,
Zoloft, Wellbutrin, Effexor and Buspar -- and wasn't designed
to compare them. All proved similarly effective and relatively
safe. The message, doctors said, was that antidepressants should
be given a 6-to-12-week chance to work, and that if one doesn't
help, another should be tried.
"It's
important not to give up if the first treatment doesn't work fully,"
or causes side effects, said one study leader, Dr. John Rush of
the University of Texas Southwestern Medical Center in Dallas.
Almost as many people were helped the second time around as the
first, he said.
Two
reports from the study were published today in the New England
Journal of Medicine.
An
estimated 15 million Americans suffer depression each year, and
it is the leading cause of disability in people ages 15 to 44,
experts said.
Nearly
two dozen antidepressants are on the market -- 189 million prescriptions
were filled last year alone -- but they are controversial. Evidence
on their effectiveness is limited, and the government recently
ordered stronger warnings that some can worsen suicidal tendencies
in teenagers in rare cases. The risk in adults is still being
studied.
The
federal study first tested Forest Laboratories' Celexa, among
the antidepressants classified as selective serotonin reuptake
inhibitors, or SSRIs.
One-third
of the roughly 3,000 who took it recovered, though they generally
took higher doses and were monitored more closely than most patients,
researchers reported several months ago.
The
new research, step 2 of the study, involved people who didn't
get well the first time around, an especially tough-to-treat group.
They had depression for 16 years on average, and two-thirds had
other mental or physical problems.
Out
of this group, 727 chose to switch from Celexa to a different
medication and were randomly assigned to get either Zoloft, another
SSRI made by Pfizer Inc.; Wellbutrin, a non-SSRI antidepressant
made by GlaxoSmithKline; or Effexor, an antidepressant made by
Wyeth that works on another brain chemical in addition to the
one targeted by SSRIs.
Roughly
one-fourth became symptom-free within 14 weeks. No big differences
were seen in safety or side effects among the drugs.
An
additional 565 patients chose to add a second drug to Celexa and
were given either Wellbutrin or Buspar, a Bristol-Myers Squibb
anti-anxiety medication that can boost the effectiveness of SSRIs.
Within
14 weeks, about one-third were symptom-free. Those on Wellbutrin
had slightly fewer symptoms and side effects than those on Buspar.
One
study participant, Kasey Thompson, a 40-year-old medical school
administrator from Fort Worth, suffered depression for nearly
20 years. Celexa helped, but she still had sleep problems and
avoided friends until she added Wellbutrin.
"Piggybacking
these two drugs together made a huge impact on my depression,"
Thompson said.
The
study will continue to test third and even fourth treatment attempts,
and to analyze genes to see if any patterns emerge with particular
drugs.
Roughly
4 out of 10 people in the study were unemployed, and nearly that
many had no health insurance. Without access to treatment and
a reduction in societal stigma toward depression, millions will
continue to suffer, he wrote.
Major
Strides in Fending Off Depression Among the Elderly. By Benedict
Carey
The New York Times, March 21, 2006
Many
elderly people are already distressed by the increasing numbers
of drugs they are taking, including painkillers and heart medication.
Now, those who are also battling depression may be wondering where
it all will end.
Last
week, researchers at the University of Pittsburgh presented findings
from a large government-financed study suggesting that antidepressants
are more effective in warding off a recurrence of late-life depression
than periodic sessions of interpersonal therapy, a standardized
form of talk treatment.
For
many elderly people and the families who care for them, the findings
may appear to make their options more confusing. Antidepressants
can cause sleeping problems, dizziness and other side effects
that can increase the risk of falls in the elderly and are associated
with odd withdrawal effects when they are stopped abruptly.
Yet
experts say that the results of the study are hardly the final
word on either drug treatment or psychotherapy for the estimated
six million older Americans who struggle with depression. When
delivered often enough and tailored to a person's specific problems,
they say, talk therapies can work at least as well as drugs in
many older people to keep despair at bay.
"If
the interpretation of this study is that talk therapy is not worth
it, or people over 70 are too old for it, that would be a terrible
outcome," said Dr. Gary Kennedy, director of geriatric psychiatry
at Montefiore Medical Center in the Bronx.
"The
fact is that talk therapy techniques for this age group are evolving
rapidly, and we have several techniques that address common sources
of depression, such as grief and social isolation," Dr. Kennedy
said.
Dr.
Charles Reynolds, the lead author of the new study, said in an
interview that the type and amount of psychotherapy that study
participants received after they first recovered — one session
a month, focused on managing personal relationships — might
not have been appropriate, given their age.
"I
think that in many patients this age there may be some cognitive
impairment, and treatments involving family members and caregivers,
or problem solving techniques, might be more effective,"
Dr. Reynolds said.
The
evidence supporting talk therapy in older people is modest but
encouraging, experts say. In a recent review, researchers at the
University of California, San Francisco, identified 16 rigorous
trials of talk therapies for depression in elderly people.
The
researchers determined that the treatments worked as well as they
did in younger adults. About a third of the people recovered,
a third improved noticeably but not entirely and the other third
remained depressed. Results from drug trials are comparable.
Given
that the elderly are likely to be suffering from chronic, emotionally
exhausting ailments like heart disease, arthritis and diabetes,
these results are reason for optimism, said Patricia Arean, an
associate professor at U.C.S.F.
"We
found improvements not only in people's mood but in how well they
function, whether they have more energy, how they're sleeping,
whether it's any easier to get the groceries, to do chores,"
said Dr. Arean, a co-author of the study, with R. Scott Mackin.
"These are very important concerns in this age group."
Take
the seemingly simple act of driving, which can be more adventurous
at 70 than it is at 40 for a parent racing between basketball
and soccer practices.
Helen
Schwartz, 79, a retired businesswoman and singer living in Yonkers,
describes her frequent drives to take her husband to the local
Veterans Affairs clinic as a study in stress management.
Her
husband, Benjamin, 85, used to be the primary driver until symptoms
of Parkinson's disease set in. He becomes very tense on these
trips, Ms. Schwartz said.
"He
doesn't really say anything but he makes sounds, he gasps, he
reacts, because he's not in control, and this just makes me more
nervous," she said in an interview. "Me, I've got arthritis,
and especially when I'm in pain, I don't like anyone talking to
me or distracting me when I'm driving."
Brief,
anxious episodes like these, combined with the still-jarring sight
of her husband looking so fragile, can sink Ms. Schwartz into
periods of gloom, and she has visited Dr. Kennedy regularly for
years to keep herself strong, she said.
In
the time, she said, he has taught her techniques to anticipate
when she will be anxious, to prepare and physically calm herself,
and to recall that she has coped with far more stressful periods.
Ms.
Schwartz, who has periodically used antidepressants and anti-anxiety
drugs, said that the therapy sessions were her most important
hedge against depression. "You can't live on pills alone,
because once the drug wears off, where are you?" she said.
"You need a deeper understanding of what's happening to you
and how to cope with it."
Therapists
who work with older people make use of a growing number of talk
treatments to address specific late-life problems that can bring
on or worsen depression.
In
an approach called problem-solving therapy, people list the specific
problems in their lives — whether with a balky water heater,
confusing bank statements or demanding siblings — and then
develop their own solutions, with the help of the therapist.
Acting
on these plans can itself lighten despair in elderly people.
Another
kind of therapy helps people understand, express and resolve longstanding
feelings of grief over losing a husband or loved one.
The
most scientifically studied technique, cognitive behavior therapy,
teaches people to identify and dispute self-degrading thoughts
— "I have been an awful parent" — that can
feed on themselves and cause people to sink into despair.
"One
thing you find with older people is that they have a lifetime
of experience in solving problems, and this experience is much
more powerful than they usually know," said Dr. Aaron Beck,
a professor of psychiatry at the University of Pennsylvania.
Whether
they favor drugs, talk therapy or a combination, therapists agree
that simple case management — helping connect people with
community services, get treatment for physical problems and complete
chores — can also help them turn the corner.
"I
must say my life is good now, better than most my age, I think,"
said Audrey Nicholson, 77, who has struggled with recurrent depression
but has been far better while being treated at the University
of Pittsburgh.
"I
just had hip replacement surgery, and I've been fine through all
that," she said. "Between the medicine and the therapy,
they've come a long way in how they can treat this."
Revisiting
Schizophrenia: Are Drugs Always Needed? By Benedict Carey
The New York Times, March 21, 2006
The
only responsible way to manage schizophrenia, most psychiatrists
have long insisted, is to treat its symptoms when they first surface
with antipsychotic drugs, which help dissolve hallucinations and
quiet imaginary voices.
Delaying
treatment, some researchers say, may damage the brain.
But
a report appearing next month in one of the field's premier journals
suggests that when some people first develop psychosis they can
function without medication — or with far less than is typically
prescribed — as well as they can with the drugs. And the
long-term advantage of treating first psychotic episodes with
antipsychotics, the report found, was not clear.
The
analysis, based on a review of six studies carried out from 1959
to 2003, exposes deep divisions in the field that are rarely discussed
in public.
In
the last two decades, psychiatrists have been treating people
with antipsychotic drugs earlier and more aggressively than ever
before, even testing the medications to prevent psychosis in high-risk
adolescents.
The
studies demonstrate that the drugs are the most effective way
to stabilize people suffering a psychosis. Millions of people
rely on them, and the new report is not likely to alter the way
psychiatrists practice anytime soon.
But
some doctors suspect that the wholesale push to early drug treatment
has gone overboard and may be harming patients who could manage
with significantly less medication, perhaps because they have
mild forms of the disorder.
About
three million Americans suffer from schizophrenia, and a vast
majority of them take antipsychotic drugs continually or periodically.
"My
personal view is that the pendulum has swung too far, and there's
this knee-jerk reaction out there that says that any period off
medication, even for research, is on the face of it unethical,"
said Dr. William Carpenter, director of the University of Maryland's
Psychiatric Research Center and the editor of the journal Schizophrenia
Bulletin, which will publish the article on April 1, along with
several invited commentaries.
Dr.
Carpenter said that while antipsychotics are central to treatment
in most cases the field's aggressive use of the drugs leaves "little
maneuvering room" to try different options, like drug-free
periods under close observation after a person's first episode
of psychosis. "It's a very controversial issue, and I thought
it was important to get it out there," he said.
Other
experts warned that the new report's conclusions were dangerous,
and represented only one interpretation of the evidence.
"I
am usually a pretty moderate person," said Dr. Jeffrey Lieberman,
chairman of psychiatry at Columbia University Medical Center and
director of the New York State Psychiatric Institute. "But
on this I am 110 percent emphatic: If the diagnosis is clear,
not treating with medication is a huge mistake that risks the
person's best chance at recovery. It's just flat-out nuts."
In
the report, John Bola, an assistant professor of social work at
the University of Southern California, reviewed six long-term
studies involving 623 people who had symptoms of psychosis.
All
of these men and women entered the studies soon after their psychosis
was diagnosed, after a first or second break from reality.
In
the studies, roughly half of the patients were promptly treated
with antipsychotic drugs while the other half went without the
medication for periods ranging from three weeks to more than six
months.
Those
who functioned well without medication remained drug free in several
of the studies. Those who relapsed received drug treatment.
Two
studies found that after a year or more the patients on a full
course of medication performed better on measures of social interaction,
work success and the risk of rehospitalization than those who
were initially drug-free.
The
other four studies found the opposite: that the less-medicated
group did slightly better. Over all, the findings of the studies
were a wash, showing no significant advantage for either group.
The
patients on full medication were taking older antipsychotics,
like Haldol; similar studies have not been carried out with newer
drugs, like Risperdal.
"The
most striking observation in this review," Dr. Bola wrote
in the paper, "is the dearth of evidence that addresses the
long-term effects of initial treatment."
Previous
reviews concluding that drugs provided significant benefits included
many studies that did not have a comparison group of people who
were not on medication, he found.
"My
hypothesis is that there is a subgroup of patients who are drug-free
responders, probably because they have a mild form the disorder,"
Dr. Bola, who has argued against aggressive drug treatment in
the past, said in an interview. "I think the implications
of this are that we need to be additionally careful about medicating
people after their first psychotic episode if there's reason to
think they could" function without medication.
Studies
suggest that 10 percent to 40 percent of people with symptoms
of psychosis can manage without medication. But there is no test
to identify these people, and psychiatrists say that withholding
drugs after a full-blown psychotic episode is highly risky. Psychotic
episodes tend to become worse over time when untreated, they say,
and the effect of the experience on the brain is still unknown.
"The
psychotic state is a crisis, an emergency; people do irrational
things, dangerous things, and the initial treatment has to be
with what works best — medication — along with an
attempt to get them into a talking relationship," said Dr.
Thomas McGlashan, a professor of psychiatry at Yale.
The
issue is most important to patients and their families. First
episodes of psychosis, which often strike in high school or college,
can derail young people at a crucial point in their lives and
even lead to suicide. John Caswell, 50, a writer and an artist
living in Lebanon, N.H., said he tried to kill himself twice after
going off medication.
"Once
I was driving around and having hallucinations, listening to a
gospel station, and I had this strong feeling that I should die
and would wake up after that and start life anew," he said
in an interview. He purposely drove his car off the road and into
a guardrail, he said.
Since
then, Mr. Caswell has managed his symptoms with Risperdal, an
antipsychotic he takes daily. He says he relies on the drug, "like
a diabetic needs insulin."
Yet
a large, study in 2005 comparing the schizophrenia drugs found
that over 18 months, about three-quarters of people stopped taking
the medications they were on because they were dissatisfied.
The
drugs have significant side effects: older medications can induce
Parkinson's disease-like tremors and the movement disorder known
as tardive dyskinesia; some of the newer drugs also induce weight
gain and increase the risk of diabetes; and in elderly people,
both classes of drugs have been linked to higher rates of premature
death.
Antipsychotic
medication also induces significant changes in brain function
that are not well understood. The drugs numb brain cell receptors
to the activity of dopamine, a neural messenger that appears to
circulate at high levels when people are in the grip of psychosis.
Ever
adaptable, the body responds by manufacturing more dopamine receptors,
which could make the brain more sensitive to future dopamine onslaughts
that are untreated, experts say.
"Medication
can be lifesaving in a crisis, but it may render the patient more
psychosis-prone should it be stopped and more deficit-ridden should
it be maintained," Dr. McGlashan of Yale wrote in a commentary
that accompanied Dr. Bola's report.
For
these reasons, many former psychiatric patients have challenged
the wisdom of treating psychosis aggressively and early, especially
for high-risk patients who have not yet shown full-blown psychotic
symptoms.
"If
I had stayed on medication, I don't think there's any way my life
would be as together as it is now," said Will Hall, 40, a
mental health advocate in Northampton, Mass., who was hospitalized
14 years ago and put on antipsychotics for about four months after
a suicide attempt.
Mr.
Hall said that he still heard voices, machine sounds and imaginary
conversations but that the hallucinations had become less threatening
over time.
"I
am very careful about the early warning signs, the noises, the
sounds, and I make sure to talk to people and resist the urge
to isolate myself," he said in a telephone interview. "People
can learn tricks, ways of dealing with symptoms so they don't
get overwhelmed."
Several
programs have helped people manage psychotic symptoms with minimal
use of medication. In one, researchers in Finland found that intensive
family therapy helped more than 40 percent of patients with early
symptoms of psychosis recover significantly without antipsychotics
— and they have remained off the drugs, for more than two
years.
Another
program, in Sweden, also has found that many people do well when
treated with low doses of antipsychotic medications, or none at
all, after their first psychotic break.
But
both countries have health care systems in which psychotherapy
and in-hospital care are readily accessible. In the United States,
psychiatrists say, taking patients off medication would leave
them vulnerable to life-altering relapses without sufficient support.
Only in research settings, with carefully informed consent, are
doctors likely to allow people suffering from a first psychosis
to go drug free, they say.
"My
bottom line is that this is a very challenging illness, every
patient is different, and we need more research to inform decisions
about how to individualize care," said Dr. John Kane, chairman
of the psychiatry department at Zucker Hillside Hospital in Glen
Oaks, N.Y.
With
certain patients, he added, "We have to be very careful about
making blanket statements about which treatment is best."
Different
Drug Often Works in Depression, Study Finds. By Benedict Carey
The New York Times, March 23, 2006
Some
people with depression who do not recover with an initial course
of antidepressant therapy can increase their chances of finding
relief by trying other drug treatments, researchers are reporting
today.
The
study is the most extensive of people undergoing multiple treatments
for depression.
The
findings underscore the benefits of treatment with antidepressants
and its limits. Although 20 percent to 30 percent of the patients
who used follow-up regimens recovered, the rest did not.
The
report is the second phase of a government-financed study that
has tracked more than 2,800 depressed adults under the care of
doctors or psychiatrists. In the first phase, reported in January,
the researchers found that one in three patients recovered while
taking Celexa, an antidepressant.
In
two papers appearing today in The New England Journal of Medicine,
the investigators report on a subset of those who did not recover.
Those patients went on to complete a different round of treatment.
Experts
said the combined recovery rate from the two phases was not certain,
because hundreds of the patients who started the trial did not
proceed to the second phase.
The
study included no comparison group. In most studies of depression,
10 percent to 30 percent of the subjects recover spontaneously
when taking placebo pills.
"The
importance of this was that it focused on remission, not response,
on treatments to help people get well, not just better,"
said Dr. Thomas R. Insel, director of the National Institute of
Mental Health, which financed the study. "And these trials
provide doctors and patients with extensive information to help
find the best strategies."
Many
of the more than 20 researchers involved in the study have consulted
widely with manufacturers of antidepressants, but the authors
said the companies played no role in interpreting the data or
writing the papers.
In
one paper appearing today, the authors report that 21 percent
of 727 people who switched from Celexa to another antidepressant,
like Zoloft, Effexor or Wellbutrin, improved. In the other paper,
the authors report that 30 percent of 565 people who supplemented
their Celexa with Wellbutrin or BuSpar, an antianxiety drug, recovered.
"One
of the big questions in the past was whether you should give up
or continue if the first antidepressant treatment fails,"
said Dr. Madhukar H. Trivedi, a professor of psychiatry at the
University of Texas Southwestern Medical Center in Dallas and
the lead author of one of the papers. "The message from this
is that if the first try doesn't lead to an optimal outcome, you
go to the next step."
The
researchers emphasized that the doctors treating the people in
the study paid careful attention to dosages and side effects and
that the patients stuck with their drug therapies for up to 14
weeks before giving up, more than twice as long as many patients
do.
One
recent study of treatment in primary care found that fewer than
10 percent of chronically depressed people achieved full recoveries.
Dr.
Donald F. Klein, a professor of psychiatry at Columbia University,
said that the study provided important data but that it would
probably not change practice much.
"Most
doctors are already convinced that you don't stop after just one
failed treatment," Dr. Klein said. "One major question
has been whether it's better to give adjunctive treatment or to
switch drugs, and the hope was that this trial would answer that
definitively. But unfortunately it didn't."
Other
experts cautioned against extrapolating too much from any study
without a comparison group of patients. Dr. David A. Freedman,
a clinical trial expert at the University of California, Berkeley,
wrote in an e-mail message that without a control group "we
can't tell if improvement is due to time, or due to treatment."
"Also,"
Dr. Freedman added, "many patients dropped out along the
way. We don't know what happened to them. How well do the drugs
work? We still don't know."
Dr.
Trivedi said further analysis should clarify some of the questions.
The researchers are analyzing data from patients who dropped out
and from those who continued on Celexa. The researchers are also
tracking a group of people who have received psychotherapy after
a failed trial with drugs.
