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5/29/2014 12:00 AM

It’s been nearly two weeks since the tragedy in Isla Vista, Calif., that resulted in the killing of six students and injuries to 13 others, and once again the mental health field is confronted about what to do in order to avert future tragedies.

It’s been nearly two weeks since the tragedy in Isla Vista, Calif., that resulted in the killing of six students and injuries to 13 others, and once again the mental health field is confronted about what to do in order to avert future tragedies.

While more details are emerging, news reports indicate that Elliot Rodger,a 22-year-old student, had been seeing therapists since he was a child. In the weeks before the tragedy, his concerned parents had called the police to check on him. Officers, however, saw no cause for alarm, according to news reports.

Meanwhile Democratic Assembly members Das Williams of Santa Barbara and Nancy Skinner of Berkeley announced they will introduce a bill that would allow concerned family members or friends to notify authorities when a loved one is at risk of committing violence. That would allow law enforcement to investigate the person and potentially prevent him from buying firearms, the Sacramento Bee reported.

Members of the mental health community are advocating for research, education and expansion of crisis-related services. The National Alliance on Mental Illness (NAMI) released a statement about the steps needed to prevent future tragedies:

  • Fill the gaps in our community mental health care systems. That includes the creation and promotion of crisis services and partnerships between mental health professionals and all first responders.
  • Improve communications between mental health professionals, individuals receiving care and their families. Mental health privacy is important, but privacy laws should not stand in the way of coordinated information and action in a crisis.
  • Talk about it — within families as well as with teachers, clergy, students and community leaders. Encourage conversation about mental health, about what we are experiencing and what we can do to help. By doing so, we create and promote the space for open and honest dialogue that saves lives.

“There are simple things that can also be looked at to improve the system to make sure this doesn’t happen again,” Katrina Gay, director of communications for NAMI, told MHW. “There’s a big gap in our community around crisis services, such as mobile crisis services, crisis intervention specialists who are trained to de-escalate [a situation].”

Gay explained that at one time such services were robustly available but that was before huge mental health budget cuts began during the recession. “Most communities only have a ‘patchwork’ of crisis mental health services at best,” she said. Crisis Intervention Team (CIT) programs are a part of that, she noted. However, there needs to be an array of assessment, crisis stabilization services and hotlines available, Gay said.

CITs know how to de-escalate in a crisis, but intervening in a crisis to provide care is another situation, she noted.

Partnerships encouraged

When Rodger’s parents contacted police, a mental health professional should have accompanied them to provide an evaluation and/or intervention, noted Gay. “Clearly someone in the family recognized a concern,” she said. “It’s not reasonable to send a police officer in those situations as a first responder.” CIT programs do help, but in this particular case somebody should have accompanied the police, she said.

In her discussion with NAMI leaders last week, Gay said the consensus was on the need for mental health providers to be a part of the crisis service array. A trained mental health provider can ask questions and has more skills about engaging an individual, she said. “Only a mental health crisis team member can determine whether a person can qualify for an intervention,” she said.

Gay added, “The system is broken. In this case, there’s very little the police could have done that would have resulted in a different outcome. We can always say ‘what if.’”

Events like this tragedy are unpredictable, said Gay. If the family knew there was a crisis and they were worried and concerned, they should be taken seriously, she added.

“There’s a huge gap in our very broken system,” said Gay. “We need to fill those gaps. Partnerships between mental health providers and law enforcement are vital to the outcome for individuals who are in crisis and struggling. It’s vital to ensure the health and safety of individuals in crisis and our community — they go hand in hand.”

More bipartisan action and agreement are needed to address the pending mental health reform bills, said Gay. “There are different pieces of legislation being discussed that have components of what we’d like to see,” she said.

Minimizing the risk

“We cannot prevent all tragedies but we can do some things that can minimize the risk,” Linda Rosenberg, president and CEO of the National Council for Behavioral Health, told MHW. “We need to get down to working on education, treatment and research.”

Like NAMI, the National Council is also promoting and supporting the need for more crisis services, which was a key area of focus during the organization’s annual conference in early May in Washington, D.C., said Rosenberg.

Rosenberg explained that for the first time during its national conference, the National Council offered a crisis track for attendees. “There’s a need to ensure that crisis services are available,” said Rosenberg. Mobile teams, crisis stabilization units, peer support, respite beds and a crisis track are all critical, she said.

The National Council is planning a series of webinars on crisis services, she said. “Our members are bringing more attention to the need for crisis services,” Rosenberg said.

Regarding treatment, Rosenberg pointed to the Excellence in Mental Health Act, which recently became a law. The Excellence Act will increase Americans’ access to community mental health and substance use treatment services while improving Medicaid reimbursement for these services. “It’s a down payment on increasing treatment capacity for individuals with both mental health and substance use disorders,” she said. “We need to make sure we have capacity.”

Nearly a billion dollars has been added to this bill, she said. The legislation calls for an eight-state demonstration program that would allow states to expand services 24/7 to support families. “It’s something we can build on,” said Rosenberg, who added that the National Council is pushing for this in all states. “We want a full payment. We will work on that.”

Research in the field is another priority. “The brain is uncharted territory in many ways,” she said. “We need a better understanding of these mental illnesses and the support of institutions like the National Institute on Mental Health [NIMH].”

“What do we know about violence and how the brain functions?” Rosenberg noted. “What goes on in the brain that motivates violence? Is it a mental illness or some other process that we’re unaware of?”

Education about mental illness as part of the National Council’s public education program, Mental Health First Aid, continues to be critical, Rosenberg said. “We’re having these conversations in communities,” she said. Teachers, aunts, neighbors and others need to know how to help people who are having a tough time, she said. “Bad things will always happen,” said Rosenberg. The field can work together to help minimize or even avert future tragedies, she noted.

5/15/2014 12:00 AM

Mental health advocates are encouraged about a mental health bill that makes new investments in prevention and early intervention, advances mental illness research and proposes a White House Office of Mental Health Policy. Despite competition from another proposal introduced five months earlier, advocates remain hopeful that Democrats and Republicans will compromise on comprehensive legislation.

Mental health advocates are encouraged about a mental health bill that makes new investments in prevention and early intervention, advances mental illness research and proposes a White House Office of Mental Health Policy. Despite competition from another proposal introduced five months earlier, advocates remain hopeful that Democrats and Republicans will compromise on comprehensive legislation.

The Strengthening Mental Health in Our Communities Act of 2014 was introduced by Rep. Ron Barber (D-Ariz.) during the National Council for Behavioral Health conference on May 5 in Washington, D.C. (see MHW, May 12). H.R. 4574 is sponsored by Barber along with Reps. Diana DeGette (D-Colo.), Doris Matsui (D-Calif.), Grace Napolitano (D-Calif.) and Paul Tonko (D-N.Y.).

Provisions in the new bill include the reauthorization of important services and programs under the Substance Abuse and Mental Health Services Administration (SAMHSA) and a White House Office of Mental Health Policy that is responsible for developing and implementing a national strategy for mental health. The proposal would ensure collaboration between mental health programs and services across federal, state and local agencies.

Rep. Tim Murphy (R-Pa.) introduced mental health legislation aimed at reforming the mental health system last December. Although those in the field were pleased that the bill includes the reauthorization of suicide prevention programs and Mental Health First Aid, they were not pleased about the bill’s proposal to cut back on the Protection and Advocacy (P&A) program for individuals with mental illness by 85 percent.

Some advocacy groups noted that Murphy’s bill would also expand the use of involuntary treatment and ignore the rights of persons with mental health conditions to make their own decisions concerning treatment. Assisted outpatient treatment (AOT) should be used as a last resort, they said (see MHW, Dec. 23, 2013).

Bill provisions

Barber’s legislation, which aims to fill significant gaps in the mental health care system, includes the following provisions:

  • Reauthorizes the Garrett Lee Smith Memorial Act for suicide prevention;
  • Emphasizes evidence-based practices that have been proven effective through empirical evidence;
  • Authorizes mental health awareness training grants to improve mental health awareness;
  • Creates a national media campaign to reduce the stigma associated with mental illness; and
  • Requires a report on evidence-based mental health practices to better serve older Americans.

Barber said that he received letters from a number of organizations, including the American Psychological Association, about issues the groups felt were important in a mental health reform bill. “That was an important factor in designing the bill,” Barber told MHW.

Barber was wounded along with then-Congresswoman Gabrielle Giffords in the shooting in Tucson in 2011 that left 13 wounded and six people dead. “At least two years prior to the shooting, the gunman, Jared Lee Loughner, displayed symptoms that we now know [revealed] deteriorating problems,” said Barber.

“The police and school saw and no one ever put it together,” he said. “If they had, this might not have happened.” That’s why Mental Health First Aid is so critical, said Barber. The legislation provides $20 million for the public education program.

Barber said he is continuing to seek sponsors for the bill. “We’re hoping the Republicans will join us,” he said. “Any attempt to make this a partisan issue is a mistake.”

Advocates weigh in

“I know that there are some folks who [view] Barber’s bill as an alternative to Murphy’s bill,” Ron Honberg, national director of policy and legal affairs for the National Alliance on Mental Illness (NAMI), told MHW. “We see it a little bit differently. Hopefully, the legislation could be viewed as a potential framework for a compromise or a 'meeting of the minds' among lawmakers," he said.

“To pass a bill in Congress you need Republican and Democratic support,” Honberg said. “The goals of Murphy and Barber’s bills are very much in synch. There are sincere efforts on everybody’s part to improve mental health services in this country. Everyone agrees the mental health system is broken.”

NAMI is very pleased about the proposal to coordinate all levels of federal funding and services, said Honberg. It also expands health insurance technology (HIT) to providers, he said. The legislation extends Medicare and Medicaid reimbursement for the use of electronic health records (EHRs) to mental health professional facilities, and makes mental health and addiction treatment providers eligible for Health Information Technology for Economic and Clinical Health Act technical assistance.

Honberg said he is also pleased about the provision that would eliminate the 190-day lifetime limit on inpatient psychiatric hospital care under Medicare. “It creates an exception to the IMD [Institutions for Mental Disease] rule,” he said. Currently, the IMD exclusion prohibits Medicaid from making payments to IMDs for services rendered to Medicaid beneficiaries aged 21 to 64.

Barber’s legislation is a “very person-centered bill rather than an institutional one,” Debbie Plotnick, senior director of state policy for Mental Health America (MHA), told MHW. The bill emphasizes important provisions for individuals, families and whole communities, she said. “People need a safe place to live,” said Plotnick. “They need coordinated supports and something meaningful to do, such as supported employment, and access to community-based services in a timely manner.”

The legislation also delves further into parity, said Plotnick, citing the provision that requires a Government Accountability Office (GAO) study on mental health and substance use disorder parity enforcement efforts. Additionally, Barber’s bill requires the Secretary of Labor to coordinate with the secretary of the U.S. Department of Health and Human Services (HHS) to prepare annual detailed reports of parity compliance activities in each state.

Individuals with mental illnesses and intellectual disabilities are residing in state institutions because there is no infrastructure for community-based programs and they have to live in restrictive settings, said Plotnick. P&A programs provide a very important function for these kinds of issues, said Plotnick. “It’s very important to P&A to continue to be able to do the exemplary work things been doing,” she said.

“We’re very much in favor of a White House coordinator for all agencies and departments, such as SAMHSA, HHS, HUD [Housing and Urban Development], DOJ [U.S. Department of Justice] and the Veterans Administration, to create an overall strategic plan," said Plotnick.

Barber’s legislation, on the other hand, places an emphasis on peer support, mobile crisis services and other programs for individuals with a mental illness before they reach a point where they’re spending hours in an ER or cycle in and out of prisons and jails, Plotnick said. “Ultimately, everybody hopes that both parties can find common ground,” she said.

Opposing concerns

DJ Jaffe, founder of Mental Illness Policy Org, told MHW that Barber’s legislation “strips out provisions that help people with a serious mental illness. It’s a mental health bill, not a mental illness bill. It gives more money to the mental health industry without requiring that any of it is spent on people with a serious mental illness.”

Jaffe said families of consumers with a serious mental illness lined up in support of Murphy’s bill. The current bill is probably well intended, he said. “We advocate for people with a serious mental illness. This bill drives funding away from programs that help people with an SMI,” said Jaffe.

“Barber’s bill increases reimbursement rates for marriage counselors, but not for treating people with schizophrenia,” said Jaffe. “The legislation does little for the 4 percent of people with a serious mental illness.”

Bottom Line…

While some in the mental health field are still split over the merits of two recently introduced mental health bills, the hope is that lawmakers can negotiate one comprehensive bill.

3/27/2014 12:00 AM

Researchers have identified a new testing process that would help behavioral health clinicians assess and treat patients with a serious mental illness who are taking Abilify (aripiprazole). The research is the first of its kind to develop a new method to assist clinicians in assessing a patient’s non-adherence to the antipsychotic medication, according to officials at Ameritox, a national pain medication monitoring organization

Researchers have identified a new testing process that would help behavioral health clinicians assess and treat patients with a serious mental illness who are taking Abilify (aripiprazole). The research is the first of its kind to develop a new method to assist clinicians in assessing a patient’s non-adherence to the antipsychotic medication, according to officials at Ameritox, a national pain medication monitoring organization

The results of a pilot study that described urine metabolites found in patients using Abilify were published in the February issue of the Journal of Pharmacology and Clinical Toxicology. According to the study, “Quantitative Levels of Aripiprazole and its Metabolites in Urine,” strict compliance to an antipsychotic medication regimen is vitally important in maximizing positive outcomes for individuals suffering from schizophrenia.

The goal of the published pilot study was to identify a method of testing for Abilify in the urine, said Jerry Vaccaro, president of Ingenuity Health, a service of Ameritox. “Medication adherence of people with a serious mental illness is far below that of people with other illnesses, such as hypertension and diabetes,” said Vaccaro told MHW.

Vaccaro added, “Non-adherence to medication is directly tied to clinical symptoms worsening, hospitalization, rehospitalization, ER use and the use of other health care services.” He pointed to a meta-analysis study conducted in 2003 that found that 86 percent of patients said they were adhering to their medication while about two-thirds of physicians said their patients were adherent.

The overarching goal of Ingenuity Health’s clinical research plan is to focus on urine drug monitoring of a psychoactive drug, Vaccaro said. About two years ago, Ameritox began focusing on antipsychotics as a class, he said. The company pioneered the development of techniques to detect antipsychotic medications in the urine. “Until now, there has not been an easy test for clinicians to use in order to monitor patients taking antipsychotic medications,” said Vaccaro.

Study methods

Abilify is excreted primarily in the feces and less so in urine, noted Vaccaro. This fact meant the researchers had to look for lesser-known metabolites that have higher renal excretion, he said. “They looked for the Abilify metabolite OPC3373 in the urine of patients prescribed Abilify in order to determine if the presence of the metabolite was a reliable indicator of Abilify usage,” he said.

Researchers from Ameritox and Georgetown University and Duke University Medical Centers worked with 20 patients to find the lowest oral dose of a drug in which the parent compound and/or one of the two major metabolites would be reliably detected in 80 percent of the urine samples.

According to the study, they chose aripiprazole, a second-generation antipsychotic and adjunctive treatment for depression that is highly prescribed in this country. Researchers also wanted to observe if serum levels of aripiprazole were similar when sampled five days apart during a period of observed dosing.

All the subjects had observed aripiprazole dosing for five consecutive days. Researchers analyzed urine samples to determine detection sensitivity for aripiprazole and the two major metabolites dehydroaripiprazole and OPC3373, the aripiprazole metabolite found in urine.

According to the study, researchers observed aripiprazole in 50 percent of the urine samples. The dehydroaripiprazole was only observed in 8 percent of the samples. Conversely, OPC3373 was observed in 93 percent of the urine samples. Urine levels of OPC3373 appear to be the most reliable marker for monitoring compliance with aripiprazole, researchers said.

Objective measures

The research findings revealed that this method is one of the first truly objective measures to identify Abilify metabolites in urine, said Vaccaro. “The larger, recently completed study, which has yet to be published, focused on development of an algorithm to assess a patient’s likely adherence to their Abilify treatment plan,” he said.

Ameritox has created testing methodologies and decision support tools in order for providers, families and patients to have intelligent, nonconfrontational conversations in a clinical setting, Vaccaro said.

Next, the company plans to look at the impact — relapse, recidivism, rehospitalization and, ultimately, the cost. “This really changes the pattern of care,” he said. Providers in clinical settings can use the test, said Vaccaro.

The company currently tests for eight antipsychotic medications, said Vaccaro. “For individuals prescribed Abilify, the patient’s urine drug test results are compared with a reference database of other people clinically assessed to be taking Abilify,” he said. Clinicians can order tests for other antipsychotic medications, said Vaccaro; however, they are detection tests only and do not yet include the reference database comparison.

Medication non-adherence has been a long-term concern, Vaccaro said. During the 1980s and 1990s, mental health providers have designed and implemented various programs, including care management and intensive care management programs (e.g., Program of Assertive Community Treatment [PACT]), education programs, and social skills training to address these concerns, he said.

“We’re looking at developing more ranges and other services in the mental health setting to help with improving clinical outcomes,” Vaccaro said. “We think this is huge for the field. It’s a game changer.”

For more information, visit www.ingenuityhealth.com or contact Lon Wagner at 336-387-7742336-387-7742.

Bottom Line…

Testing for Abilify (aripiprazole) in a patient’s urine can help behavioral health clinicians determine medication adherence and make appropriate treatment recommendations.

From the Field
9/26/2013 12:00 AM
FromtheField
8/7/2013 12:00 AM
In Case
7/11/2013 12:00 AM
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    Valerie Canady, managing editor of Mental Health Weekly, knows the mental health field inside and out. She uncovers the essential stories and gets the scoop directly from leaders and advocates in the field.
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