Category: Systems

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Education Funding Policy Systems

Jail Costs versus Hospital Costs.

We received the State of Washington Voters’ Pamphlet in the mail today. One of the initiatives, I-1401, concerns “trafficking of animal species threatened with extinction”.

Have no fear: This post is unrelated to trafficking of animal species threatened with extinction.

The “Fiscal Impact Statement” includes a statement about jail costs (highlighted for emphasis):

jailcost

“No wonder why people with psychiatric conditions end up in jail!” I exclaimed. “It’s so much cheaper for them to be there!”

Information about hospital costs are public. This page shares inpatient hospital rates for people who have Medicaid insurance in August 2015. All the hospitals in Washington State are listed in the leftmost column. One of the columns has the title “Psych_ Per Diem”. That column tells you how much money each hospital is paid if a patient with Medicaid is admitted there for psychiatric reasons. First, you will note that hospitals are paid[1. Forgive the passive voice when I write “hospitals are paid”. In Washington, hospitals send bills for Medicaid patients to the state. The state pays the hospital bill. The state then turns around and sends a bill to the region that the patient “belongs” to. The region then pays that state bill. The region gets money to pay that bill from a mix of federal and state Medicaid dollars, which ultimately come from taxpayers. Confusing, right?] different amounts. That alone is fascinating—what accounts for that? who decides how much money each hospital will receive?

More to the point, it costs anywhere between $711.55 and $1788.93 per day for an adult with Medicaid to stay in a hospital. The average cost of incarceration in Washington is $88 per day. Thus, it is at least eight times cheaper for someone to stay in jail than in a psychiatric hospital.[2. This page shares inpatient hospital rates for people who don’t have any insurance. Note that the rates are lower compared to the Medicaid rates. They are nonetheless still much higher than the daily jail rate.]

On the one hand, the differences in cost aren’t surprising: Hospitals often have more staff, equipment, and services. On the other hand, we also know that jails are often the largest psychiatric hospitals in any given region. For example, in Seattle, the jail has about 120 psychiatric beds. The largest psychiatric hospital in Seattle has about 61 beds.

I really want to believe that no one intentionally designed the system this way. Surely no person or system could be so heinous and miserly to funnel people into jail instead of a psychiatric hospital. Right?

Right?

But, then the disgust kicks in: What if the costs were reversed? What if it cost $88 a day for someone to stay in a psychiatric hospital and $712 a day for someone to stay in a jail? Would we see as many people with psychiatric conditions in jail? Of course not.[3. To be clear, we should also help people stay out of psychiatric hospitals, too. Inpatient services should be available if people need them, but let’s focus on prevention and help people stay in their communities. Being in a hospital generally sucks.]

It shouldn’t be all about money, but when the cost differences are that big, money has undue weight. If we actually want to help people with psychiatric conditions, we must pay for services. Otherwise, we will only see more and more of them in jail.

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Education Medicine Observations Systems

Everything Changes, Nothing Changes.

The Mutter Museum Instagram account recently posted this photo:

Thorazine

“Thorazine” is the trade name for chlorpromazine. It is considered the medication that ushered in the “psychopharmacological revolution”, thus allowing some patients to leave psychiatric institutions. (You can read the interesting history of chlorpromazine here. Spoiler alert: It was designed for use in surgery, not psychiatry.)

Chlorpromazine is often touted as the first medication that could reduce symptoms of schizophrenia. Other FDA-approved “psychiatric” uses of chlorpromazine[1. Other FDA-approved uses of chlorpromazine that are unrelated to psychiatry include acute intermittent porphyria; intractable hiccoughs; nausea and vomiting; and tetanus, “adjunct”.] include:

  • Apprehension, presurgical
  • Bipolar disorder, manic episode
  • Problem behavior, severe

I don’t know the context of the ad (who was the intended audience: physicians? patients? husbands?). One wonders why the ad features a woman and puts greater emphasis on “emotional stress”. A hefty dose of chlorpromazine will result in “prompt” sedation that will give someone—perhaps not the patient—”sustained relief” for several hours.

Did physicians in that era tell patients that the original use of this medication was for schizophrenia? Or did physicians focus primarily on the tranquilizing effects of chlorpromazine for those individuals who had more neurotic, not psychotic, symptoms?

Everything changes, nothing changes. Quetiapine (tradename: Seroquel) was also developed for the treatment of schizophrenia. Now, its uses include:

(1) add-on treatment to an antidepressant for patients with major depressive disorder (MDD) who did not have an adequate response to antidepressant therapy; (2) acute depressive episodes in bipolar disorder; (3) acute manic or mixed episodes in bipolar disorder alone or with lithium or divalproex; (4) long-term treatment of bipolar disorder with lithium or divalproex; and (5) schizophrenia.

The header for the page (what shows up on the browser tab) doesn’t even list the drug’s name. It says only “bipolar disorder medication”.

If you search for “Abilify” (generic name: aripiprazole) on Google, the brief summary that shows up under the first link says:

Official pharmaceutical site for this antipsychotic medication indicated for the treatment of schizophrenia.

However, when you actually go to the official website, the listed uses include:

Use as an add-on treatment for adults with depression when an antidepressant alone is not enough
Treatment of manic or mixed episodes associated with bipolar I disorder in adults and in pediatric patients 10 to 17 years of age
Treatment of schizophrenia in adults and in adolescents 13 to 17 years of age
Treatment of irritability associated with autistic disorder in pediatric patients 6 to 17 years of age

Asenapine (trade name: Saphris) also has approval to treat both schizophrenia and bipolar disorder. Should we be surprised if paliperidone (trade name: Invega[2. Does it mean anything that, of the five photos on the landing page for paliperidone, only one of them features white males?]) and iloperidone (trade name: Fanapt) soon also receive FDA approval to treat conditions other than schizophrenia?

This is why skepticism is indicated—nay, essential—whenever people exclaim with confidence that “we” understand the biology of psychiatric conditions. We live in an era where cancer drugs can be designed to interact with specific receptors because scientists have located and studied those specific receptors. That specificity does not exist in psychiatry. If it did, one drug class would treat one condition, not four.

While I am probably more reluctant than the “average” psychiatrist to prescribe medications, I believe that, for some people with significant psychiatric conditions, medications can offer great benefit. First, however, do no harm.

It is frustrating when many in the field of psychiatry insist that the serotonin hypothesis is true when, in fact, it is just a hypothesis that is probably false. Also frustrating are the multiple forces that insist that medications are the primary and sole forms of treatment for psychiatric conditions. What about exercise? Therapy? Diet? Social support?

If medications alone could successfully treat these conditions, wouldn’t the pharmaceutical companies have saved us all by now?

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Education Homelessness Observations Reflection Systems

Do People Choose to be Homeless?

One of the things we talked about during dinner was whether people choose to be homeless.

“Yeah, it seems like some people want to be homeless,” he said.

“No… I don’t think so,” his friend replied.

They looked at me.

I cannot speak for all people who have ever been homeless. However, I have several years of experience working with people who were homeless and refused housing again and again[1. When working within a housing first model, the goal is to give people housing without any expectations that people will participate in mental health or substance abuse treatment. The goal is really just to get them inside.], as well as people who left their housing and returned to the streets.[2. In my experience, people who leave housing usually return to street homelessness. Most do not return to the shelter system.]

Thus, I believe that people who are homeless do not want to be homeless. They usually have concerns about the housing offered to them.

Here are some reasons people have shared with me when I have asked them why they don’t want housing:

I can’t move in anywhere. I have to stay outside. The aliens say that if I move in anywhere, they will exterminate me. I’ve already been exterminated three times. I don’t want to get exterminated again.

I don’t want to live inside. It never feels safe. Bad things happened to me when I’ve been inside. It’s too hard to get away.

But I don’t need your housing. One day my boss will hire me again–I was really good at my job–and when I start working again I can pay for my own apartment. (This man, for years, sat on the sidewalk across the street from the building where he said he previously worked.)

There’s too many rules: Curfew at 10pm? No guests? What if I want to bring a lady friend over? Nope. Don’t want to deal with all that.

I know that place. There’re too many people using dope. I know what’s gonna happen if I am around that crowd. I’m trying to stay away from all that.

That place? Isn’t that where all the crazy people live? No, thank you–I don’t want crazy neighbors.

If I could move in without giving my name or social security number, then, yes, I’ll move in. But people keep asking me for personal information and I don’t know what the government will do with that.

So, the reasons people give generally fall into three categories:

  1. People want freedom and don’t appreciate the constraints of rules.
  2. People are concerned about their safety within the building. These reasons may or may not have any basis in reality.
  3. People may feel some guilt or shame related to the housing (whether they deserve it, what it would mean if they moved in, etc.).

It’s hard for those of us who have a stable place to live[3. One consequence of working with people who are homeless is that you never stop giving thanks that you have a place to live. You don’t have to worry about where you’re going to sleep that night. You don’t have to worry that someone might try to rob you or set you on fire. You don’t have to worry about the police picking you up simply because you have nowhere else to go. These are the things we all take for granted.] to understand why some people seem to “choose” to live outside. Sometimes people point to Maslow’s hierarchy of needs and ask, “But isn’t housing a physiological need? People need water, food, and shelter. Why would someone ignore this basic need?”

Yes, shelter is a basic need. However, people who live outside can and do meet their basic needs, including shelter. They sleep in abandoned buildings, underneath bridges, in tents, in covered doorways, in wooded groves, in bus shelters, etc. These are not ideal places to live, but they’re sufficient.

No one wants to be homeless. What they want is psychological safety. For those individuals who decline housing, sometimes the need for psychological safety will override what seems like the “logical” choice of accepting housing.

People continue to astound me with their resilience. When people resist housing for years, though, it makes me wonder what happened to them that resulted in this resilience.

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Medicine Nonfiction Observations Seattle Systems

On What Medical Directors “Should” Look Like.

I recently answered a survey about race. One question asked:

“If you ask to speak to the leader of your organization, can you expect to see someone of your race?”

I snorted. I didn’t mean to. I just had never thought about that before.

In my previous job my title[1. As I have noted elsewhere, “titles, at the end of the day, are just words.“] was “medical director”. During the first few months of that job the title felt alien to me. It was as if people at work said, “Oh, Dr. Yang? She’s the one over there with the blonde hair.” Meanwhile, I’d touch my black locks, feeling perplexed.

Early on I conducted interviews to hire staff. One applicant, a psychiatrist, was a Caucasian man in his early 50s. His greying brown hair was cropped close to his head. A striped burgundy necktie adorned the light blue dress shirt underneath his navy blue suit. Cuff links poked out from under his sleeves. A silver pen was clipped into the breast pocket of his jacket.

Turning to the program manager, I murmured, “THAT guy looks like a medical director, not me!”

She, a Caucasian woman, laughed before she said, “Yeah, you’re right!”

In the jobs I’ve held the medical directors have all been Caucasian males, with the exception of my first job: He was Asian. In residency training the chair of the department was a Caucasian male. The paintings and photographs of leadership that lined the halls of the medical school were all of aging Caucasian men.

That’s how I came to learn that medical directors don’t look like me; they’re older white men.

Leadership at this agency believed I had sufficient qualifications and hired me, an Asian female, to serve as the medical director. However, the idea that someone in this position “should” be an older white male persisted in my mind.

What does it mean that I felt doubts about my ability to work as a medical director simply because of the way I look?[2. While this post is focused on race, it could easily focus on sex, too: Most medical directors are men.]

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Consult-Liaison Education Medicine Observations Policy Systems

Buprenorphine and Other Controlled Substances.

I recently completed the buprenorphine waiver training. Buprenorphine, itself a partial opiate, is a medication that can be prescribed to patients who have opiate use disorders (e.g., taking Oxycontins or injecting heroin to get high). A physician must complete an eight-hour training and take an exam to become eligible to prescribe this medication. The physician must then apply for a specific “X license” through the DEA to prescribe it.

In some ways treatment of substance use disorders is the most evidence-based practice in psychiatry. When talking about opiate use disorders, for example, we can talk about specific mu-opioid receptors and their roles in pain and intoxication. We can discuss how drugs—both illicit and licit—work on these receptors and why certain medications can reduce or eliminate illegal drug use. This logic satisfies the analytical mind.

Since completing this training I have wondered: Why must one undergo a specific training and obtain a separate DEA license to prescribe buprenorphine?

With my current licenses I could prescribe all forms of pharmaceutical morphine (e.g., Oxycontin and Dilaudid), which can lead to severe physical and psychological dependence. Which could then result in the intervention of buprenorphine.

As a psychiatrist I would likely arouse the suspicions of the DEA if I prescribed opiate medications. That’s outside the scope of a psychiatrist’s practice.

However, it is not outside of the scope of a psychiatrist’s practice to prescribe benzodiazepines (e.g., Valium and Xanax), which are Schedule IV drugs (“a low potential for abuse relative to substances in Schedule III”).[1. You can learn more about controlled drug “schedules” on the DEA website.] I can also prescribe Schedule II drugs (“high potential for abuse which may lead to severe psychological or physical dependence”), such as Adderall and Ritalin. Physicians are not required to go through any special training or obtain separate licenses to prescribe those medications. Once I got my DEA license, I was free to prescribe these without anyone looking at me askance.

And, get this: buprenorphine is a schedule III drug!

The training offered the Harrison Narcotics Tax Act of 1914 as one reason behind the training requirement: This law suggests physicians can prescribe opiates as part of “normal” treatment, but not for treatment for addiction. Addiction was not considered a disease in 1914. Thus, if addiction is not a disease, no intervention is indicated.

That explanation, however, doesn’t make sense. There is growing consensus that substance use disorders are diseases. Nothing, other than my good judgment, prevents me from cranking out prescriptions for stimulants and benzodiazepines. Use of either medication can lead to addiction. What makes opiates so special?

The consequences of the buprenorphine training are not slight: The eight-hour training alone likely deters some physicians from pursuing it. The extra licensure is also an obstacle, as well as the consequences of using the license: No one wants regular, but unannounced, DEA audits (which, just to be clear, doesn’t happen with when one prescribes benzodiazepines or stimulants). No one is eager to maintain the documentation that is required when one prescribes buprenorphine.

It just makes me wonder what the actual story is….