Finding a good psychiatrist is a challenge, but as it turns out it may even be hard to see a mediocre or poor psychiatrist. This is particularly true for individuals who have both psychiatric problems (like depression) along with alcohol, substance abuse, or other addictions.

Deceptive insurance company practices
According to Mark Moran, writing in the April 3, 2015 issue of Psychiatric News, access to psychiatry appears to be an area in which many health plans are offering deceptive products. This problem has been studied for many years in Maryland, near the nation's capital, where access to care has long been a troubled business. Previous studies done over the last 25 years by MHAMD and other organizations found there were long delays for individuals to access psychiatric care. In 1988, MHAMD published, “Study of Mental Health Coverage Provided by Maryland HMOs.”
This study sought to provide a comprehensive picture of the impact of HMOs on access to mental health care. The anecdotes from mental health professionals in 1988 illustrated the long wait times their patients faced when trying to secure an appointment with a psychiatrist. As a follow-up, in 2002, the Mental Health Coalition of Maryland conducted a survey of mental health professionals to ascertain how the managed care system affected an individual’s ability to access mental health care.

Psychiatrists dropping our of private insurance networks
Many respondents reported dropping out of private insurance networks, resulting in more consumers having to pay out of pocket for mental health care. In 2007, the Maryland Psychological Association published a white paper titled, “Access to Care in the State of Maryland.” Their survey found that 44% of mental health professionals listed in the managed care networks were unreachable, and that the average wait time for an appointment with a psychiatrist was 25 days.
In the same April 2015 article, attorney Colleen Coyle, general counsel for the American Psychiatric Association, said that "in many instances health plans advertise provider networks that appear to offer users of behavioral health services a wide range of option for access to care, but in reality those networks may be much "thinner" than consumers are led to believe.

Insurance false advertising is fraud
"In my view, that is fraud," Coyle said. The insurer is promoting a provider list that it knows is not reflective of the access to care that patients will really have. I don't think it's innocent at all."
She goes on to say that insurance plans are constantly looking at their providers and and claims "because that's how they target which providers to audit and whether they are going to challenge the claim."
John McIntyre, M.D., a past president of the American Medical Association, said: "Many insurers, in an attempt to hold down costs, employ very narrow or shallow networks that are inadequate to provide necessary medical care. But patients don't know that when they sign up."

The detailed report from The Maryland Mental Health Association is available online here.

Tags: access to care, network adequacy, psychiatrist hard to find

SEEKING TREATMENT: KNOW WHAT TO ASK

My goal in helping people includes educating them about what questions to ask.
Finding the right treatment for a person’s specific needs is critical. And finding the right treatment is not easy. Drug and alcohol addiction treatment is not “one size fits all.”

Treatment outcomes depend upon:

• the extent and nature of the person’s problems;
  • the appropriateness of treatment;
• the competence and skill of clinical staff;
  • the availability of additional services; and
  • the quality of interaction between the person and the treatment providers.
  

Family and friends play important roles in motivating people with drug problems to enter and remain in treatment. However, trying to identify the right treatment programs for a loved one can be a difficult process.

The National Institute on Drug Abuse (NIDA) has sound advice about the five questions to ask when searching for a treatment program:

1. Does the program use treatments backed by scientific evidence?
In the internet era, answering this question has become increasingly difficult. Many programs offer flashy "treatments" that are not scientific at all, despite claims made on beautiful web pages. According to Thomas McLellen, professor of psychiatry at the University of Pennsylvania, 90% of patients who enter addiction treatment programs don’t receive evidence-based treatment. Many current programs actually reject scientific evidence. For example, they prohibit the use of addiction medications, even though they’ve been shown to be more effective treating some addictions (specifically, the range of opiates like Oxycontin to heroin) than anything else. My concern is a bit different from Dr. McLellan's view (for example, he is not friendly toward 12 Step work). My major concern is that there are dozens of quack therapies, ranging from nutritional "cures" to "new age" approaches, to potentially harmful "trauma therapy."

A great website is not a guarantee that the advertised program is any good at all. Many programs today, using clever marketing, take advantage of opposition to Alcoholics Anonymous and 12 Step Programs by advertising that says, "We are NOT a 12 Step Program!" What these programs fail to do, in almost every example, is to state clearly what they actually do in their approach. Many other websites—and I have reviewed hundreds of them—claim to offer "evidence based treatment," when in fact the program is not evidence based at all. The average person has no idea whether or not claims of scientific evidence are true. Above all, beware of "testimonials" and celebrity endorsements. In selecting a treatment program, you have to use at least as much good judgment as you would use if you were buying a new car or having heart surgery.

Effective alcoholism and addiction treatments can include cognitive behavioral therapy, medications, or, ideally, the combination of both.

Key elements include:
• addressing a patient’s motivation to change;
• providing incentives to stop drinking or using drugs;
• building skills to resist alcohol/drug use;
• replacing addiction related activities with constructive and rewarding activities;
• improving problem-solving skills; and
• building better personal relationships.

Any and every good addiction treatment program will include competent assessment by a qualified addiction psychiatrist. Some programs will team an addiction medicine doctor with a well-qualified clinical psychologist, and that can work well. The point is that everything begins with getting the right assessment. Medications are an important part of treatment for many patients, especially when combined with counseling and other behavioral therapies. Different types of medications may be useful at different stages of treatment: to stop alcohol and drug abuse, to stay in treatment, and to avoid relapse.

2. Does the program tailor treatment to the needs of each patient?
No single treatment is right for everyone. The best treatment addresses a person’s various needs, not just his or her alcohol and drug abuse. Matching treatment settings, programs, and services to a person’s unique problems and level of need is key to his or her ultimate success in returning to a productive life. It is important for the treatment approach to be broad in scope, taking into account a person’s age, gender, ethnicity, and culture. The severity of addiction and previous efforts to stop using drugs can also influence a treatment approach.
The best programs provide a combination of therapies and other services to meet a patient’s needs. In addition to addiction treatment, a patient may require other medical services, family therapy, parenting support, job training, and social and legal services.
Finally, because addictive disorders and other mental disorders often occur together, a person with one of these conditions should be assessed for the other. And when these problems co-occur, treatment should address both (or all conditions), including use of medications, as appropriate.
Medical detoxification is a necessary first step in the treatment of certain addictions, but by itself does little to change long-term drug use.

3. Does the program adapt treatment as the patient’s needs change?
Individual treatment and service plans must be assessed and modified as needed to meet changing needs.
A person in treatment may require varying combinations of services during its course, including ongoing assessment. For instance, the program should build in drug monitoring so the treatment plan can be adjusted if relapse occurs. For most people, a continuing care approach provides the best results, with treatment level adapted to a person’s changing needs. A patient’s needs for support services, such as day care or transportation, should also be met during treatment.

4. Is the duration of treatment sufficient?
Remaining in treatment for the right period of time is critical. Appropriate time in treatment depends on the type and degree of a person’s problems and needs. People argue about this point all the time, and I don't have the patience or space on this blog to cite the references, but research tells us that most addicted people need at least three months in treatment to really reduce or stop their drug use and that longer treatment times result in better outcomes. The best programs will measure progress and suggest plans for maintaining recovery. Recovery from drug addiction is a long-term process that often requires several episodes of treatment and ongoing support from family or community. If you have read this far and are starving for the references, contact me.
Relapse does not mean treatment failure. The chronic nature of addiction means that relapsing to drug abuse is not only possible, but likely, similar to what happens with other chronic medical illnesses—such as diabetes, hypertension, and asthma—that have both physical and behavioral components. And like these illnesses, addiction also requires continual evaluation and treatment modification if necessary. A relapse to drug use indicates a need to re-instate or adjust treatment strategy; it does not mean treatment has failed.

5. How do 12-step or similar recovery programs fit into drug addiction treatment?
Self-help groups can complement and extend the effects of professional treatment. The most well-known programs are Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Cocaine Anonymous (CA), all of which are based on the 12-step model. This group therapy model draws on the social support offered by peer discussion to help promote and sustain drug-free lifestyles.
Most drug addiction treatment programs encourage patients to participate in supportive therapy during and after formal treatment. These groups offer an added layer of community-level social support to help people in recovery with abstinence and other healthy lifestyle goals.

To order NIDA materials, please go to: http://drugpubs.drugabuse.gov.

Tags: addiction treatment, addiction, addiction medicine