WHY I DON'T LET INSURANCE COMPANIES TELL ME HOW MUCH I CAN CHARGE FOR HELPING MY PATIENTS

Almost two years ago I decided to not accept the limitations that insurance companies place on what I charge.  Insurance companies reimburse psychiatrists for a brief "medication check."  This often translates into a 10 minute session during which there is discussion of how the person is doing in general, an evaluation of current symptoms and response to the medication, review of any side-effects to the medication, decisions regarding any dose changes or change to a different medication, and finally a plan for evaluating the response to the medication and possible side-effects.   That is a lot to cover in a short amount of time.  I do not believe that it can be done in 10-15 minutes.  It takes more time to cover all of these areas that are important for anyone taking medications.  I have found that this can not be rushed and that improvement is related to the time spent listening and interacting and coming to joint decisions regarding the treatment. This is true whether it is focused on medication or other forms of treatment.

I have also found that the time spent is important to be able to assess the level of stress each person is experiencing and then develop ways to help that person reduce their stress level.  This is very important to overall improvement and is a major factor in increasing positive responses to medication.

I also have seen the importance of making the treatment fit the individual person. This influences the type of medication that I prescribe and allows for a determination of the optimum dose of medication. One size does not fit all. Even if one can guess that based on statistics with large numbers of people a certain dose range is likely to be helpful for any one person, it still makes a difference to discover a specific dose that is helpful for each person.  

Individualizing treatment for each person is also important when evaluating some laboratory [blood test] results, especially those involving hormones such as the thyroid.

All of the above takes time and I will not compromise this to fit reimbursment limits from insurance companies.  I have found that even though it costs more initially to see me, the positive results and improvement lead to a significantly improved quality of life and is worth the investment.

For more about my philosophy of treatment, please see the "PHILOSOPHY" section of this website.

BIPOLAR DISORDER, TYPE II...WHY IT IS IMPORTANT

Bipolar II disorder [I will refer to this as BP2 for rest of blog] made the news when it was reported that the actress Catherine Zeta-Jones was given this diagnosis.  Most people are aware of bipolar I disorder [BP1] yet BP2 is more prevalent and has significant levels of morbidity [the impact of the illness on one's life] and mortality [it can lead to suicide].  Also, and very importantly, BP2 is often misdiagnosed as frequently people with BP2 initially present to general medical settings and not psychiatric settings where they are likely to be diagnosed with a major depression and treated with antidepressants.  This happens in psychiatric settings as well.

BP2 is diagnosed if someone has had one or more major depressive episodes [MDEs] with at least one hypomanic episode.  In contrast, someone with BP1 has had at least one manic episode and usually one or more MDEs.  Differentiating BP1 from BP2 requires being able to determine if there has been a manic episode vs only hypomanic episodes.  Manic episodes involve periods of persistent and abnormally elevated, expansive or irrirtable mood  lasting at least one week.  Change in mood must be accompanied by at least three of the following if mood is elevated and at least four if mood is irritable. These include: 1. inflated self-esteem or grandiosity, 2. decreased need for sleep, 3. more talkative than usual, 4. flight of ideas or the subjective experience that thoughts are racing, 5. distractibility, 6. increase in goal-directed activity or psychomotor agitation [very restless and anxious], and 7. excessive involvement in potentially dangerous activities.  The manic mood causes impairment in functioning. Hypomanic episodes involve a period of persistently elevated, expansive or irritable mood, lasting for at least four days and it is clearly different from the person's typical depressed mood. The hypomanic mood is accompanied with the same list of possible symptoms as for manic epsiodes and must be clearly a change in functioning and observable to others but not to level of impairment. 

Another very important distinction must be made between BP2 and Major Depressive Disorders [MDD] as they do not involve any hypomanic episodes, while BP2 involves MDEs and hypomanic episodes.  If someone presents with an MDE, the only way to determine if they have BP2 is to find out if they have had any hypomanic episodes in the past.  This can be difficult as often people do not consider hypomanic episodes as problematic or pathologic and may not recall them even with direct questioning.  This is one reason that it can take over ten years to correctly diagnosis BP2.  I have treated people who have had seven different trials of antidepressants with an initial improvement and then worsening of their moods only to try another antidepressant.  This can lead to a lot of suffering and risk of suicidal behavior.  

So, how common is BP2? Lifetime prevalence rates in the US = 1.1%.  It often is associated with panic disorder, substance use disorders and ADHD.  Importantly, the depressive episodes for BP 2 compared to those for MDD were associated with more suicidal thoughts, hypersomnolence [increased sleeping] and higher rates of agitation. BP2 moods are also more seasonally influenced [more depression in later fall and winter].

Therefore, while there are some things that distinguish BP2 depression from MDE depression, the diagnosis still rests on identifying hypomanic episodes.  Be alert for these in anyone you know who has had a MDE as early treatment can make a big difference in quality of life for those with BP2.  

ANXIETY IN NANOSECONDS, WHAT CAN YOU DO?

Over the past several months I have helped a number of people who have had traumatic experiences that keep bothering them even after they are no longer exposed to the traumatic situation[s].  They report becoming very anxious very rapidly when anything reminds them of the traumatic events.  They often have develped a number of good coping skills but they are always having to use them after the anxiety has been triggered.  In trying to understand this, I recalled reading a study that found that the amygdala can respond in nanoseconds when our brains feel that something overwelming may occur.  In other words, the brain continually scans our environment and our reactions looking for potential danger.  If we have been trauatized in the past, our brains will frequently see the possibility of danger and will trigger the amygdala very rapidly.  A nanosecond is one millionth of a second!

I have found that treating the anxiety after it has been triggered can reduce the intensity of the anxiety but not lower the frequency of it.   The problem with treating the anxiety before it occurs is that the medication to reduce the anxiety needs to be present all the time and be well tolerated in between times when there is not anxiety symptoms but also be able to contain the anxiety so the amygdala is not triggered.  I have had success with low doses of atypical antipsychotic medications with monitoring for metabolic side-effects.  I do not know yet how long these medications will need to be taken.