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Should Lamictal Make Us LABILE: “A Review of the Lamotrigine and Personality Disorder” - written by Dr. Joshua Stein

2/1/2021

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At times, psychotropic decision making can feel more like an art form than science. Decision trees based on various trials inform the prescriber, but often are based on having the correct diagnosis in the first place. Lamotrigine is increasingly prescribed in when the primary diagnosis is “Emerging Borderline Traits” or Borderline Personality disorder (BPD). Compared to alternative mood stabilizers, especially the atypical antipsychotic class, it appears to have a more tolerable side effect profile with potential for benefit. While lamotrigine is just one of many medications used off label in treating symptoms of BPD, it warrants investigation.
 
In 2018 the UK National Health Service (NHS) attempted to clarify this very point with the “
  • …test whether or not prescribing lamotrigine in addition to usual treatment reduces symptoms of this condition, improves social functioning and quality of life, reduces the incidence of suicidal behavior, reduces the level of alcohol and substance misuse and lowers the amount of antipsychotic and other psychotropic medication that people are prescribed. 
 
LABILE resulted in over 270 patients with BPD separated into a lamotrigine arm and placebo arm. Each arm received normal treatment as well. Review of the study demonstrate reliable and valid results. Patients were recruited from NHS treatment centers and demonstrated severity across the spectrum of the condition.
 
To put it simply, in as real world a study as possible, with the largest number of patients yet, lamotrigine did not hold up the initial suggestion of benefit from earlier research. Results between placebo and lamotrigine treatment were equivocal. Levels of depression, the likelihood of self-harming or suicidal behavior and likelihood of problem drug or alcohol use were all comparable across the groups at follow-up. Social functioning was also equivalent across groups. 
 
Additionally, medication compliance was poor for all patients after 12 weeks, with only thirty three percent demonstrating consistency. In a medication where inconsistent/rapid titration can be life-threatening this can be especially concerning. The indication is that lamotrigine, similar to all other medications, does not treat or alleviate BPD symptoms. It adds cost and risk. 
 
A notable risk of lamotrigine is that of Steven’s Johnson Syndrome, a serious and life threatening blistering rash of mucosa and skin. When the medication is titrated too quickly, the risk increases markedly. After a two days of missed medication the 2 week titration schedule for lamotrigine must be started again. Poor compliance with
this medication certainly places patient at greater risk.
 
On the other hand, there is some reason to conclude hopefully regarding BPD. The interaction with the physician was stabilizing. The indication of having a legitimate treatable condition was validating. However the lamotrigine did not add to this benefit any better than an inert placebo.  
 
BPD warrants treatment. Patients with the disorder have a completed suicide rate greater than fifty times the general population. They utilize emergency and clinic resources to an extensive degree. Anti-depressants fair worse than placebo. Benefits of atypical anti-psychotics match placebo. Sadly, lamotrigine, much like many medications before it, once scrutinized does not meet the hope of its initial small studies and open label trials.
 
Therefore do not fall into the trap of avoiding the valid and successful treatment of Dialectical Behavior Therapy and Mentalization Based Therapy.
 
Crawford MJ, Sanatinia R, Barrett B, et al. Lamotrigine for people with borderline personality disorder: a RCT. Southampton (UK): NIHR Journals Library; 2018 Apr. (Health Technology Assessment, No. 22.17.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK493476/
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When to Refer to Psychiatry: Practical consideration for the primary care provider

10/5/2020

6 Comments

 
In the practice of medicine, there are clear moments where a specialist is needed. Seizures require a neurologist. Leukemia requires a hematologist. In mental health, there are similar lines in the sand. Acute mania requires psychiatry, commonly on an inpatient unit. Management with clozapine requires a psychiatrist. Electro-convulsive therapy requires a psychiatrist. 

However for less severe/complicated conditions, the potential to refer is often less clear. The following considerations may help extend care in the primary care setting or lead to a need for a referral:
  1. Comfort with psychotropic medications: Many primary care providers have comfort with an SSRI/SNRI or two, one methylphenidate medication and one amphetamine. This is quite appropriate and can lead to substantial healing for patients. In PAL trainings, we stress the need to build comfort with a few meds including an ability to reach therapeutic dosing. Referrals often come when those initial trials do not work or cause side effects. Calls to PAL can assist in setting up an appropriate second or third trial. Additionally, tapers and cross titrations are often stress points that lead to referral. Please call for coaching based around half lives of medications. The need for a mood stabilizer or anti-psychotic medication can also often lead to referrals. Consider a call to PAL to assist in safe initiation to avoid care delays if patient is waiting for psychiatric care.
  2. Access to psychiatry: In urban settings, referral may be easier with less obstacles to access. In rural settings, waitlist time can be substantial. Notably, the current pandemic and the easing of virtual health policy has decreased geographic access issues. Consider using fasttrackermn.org as a method to find specific care. When psychiatry is needed, especially for diagnostic needs, consider calling PAL to start appropriate care and referrals.
  3. Safety: Frustratingly, when safety rapidly becomes a concern, a patient is more likely to see an inpatient psychiatrist or emergency room physician before they see a psychiatrist. Self-injury remains common, and when it's not a normal part of day to day practice, this can lead to concern and rapid care escalation. Once this begins, consider engagement with psychiatry for assistance and ability to clarify needs of the patient. For chronically suicidal patients, psychiatry is warranted and should not be delayed unless care for those with mental illness has become the mainstay of your day to day practice.
  4. Support from additional service lines: Correct psychiatric diagnoses are needed to provide correct treatment. Information from therapists, teachers, case managers, occupational therapists, nursing home aids etc, can help inform diagnostics and benefits/side effects of medication. Collaboration with the these care modalities can bolster confidence in correct treatment and lead to early effective care and delay psychiatric referral.
  5. Practical mentorship availability: Mentorship and support can lead to increased comfort with psychiatric diagnoses in the primary care setting. Curbside consults, PAL calls or touching base with those who have longitudinally worked with mental health patients, may support each step in care leading to an extension of primary care services.
  6. Specific medication needs: Certain medications warrant psychiatric treatment. This list is extensive but includes: lithium, clozapine, antipsychotics, MAOI class antidepressants and clomipramine, to name a few. Often, primary care providers may need support in managing the medical needs of patients on these medications. It is appropriate to call the psychiatrist prescribing or PAL if questions/concerns arise.

The list above displays some of the considerations when referring to psychiatry. Access delays are not uncommon. If you are questioning a referral it would be appropriate to immediately refer to avoid morbidity while waiting for an appointment. Again, PAL can assist in bridging care in the meantime when needed.

​- Dr. Joshua Stein

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Suicide Prevention and Postvention

9/1/2020

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From the Rocky Mountain Mental Illness Research, Education & Clinical Center, located at the Rocky Mountain Regional VA Medical Center in CO:

The “How to Talk to a Child about a Suicide Attempt in Your Family” booklet/DVD was created to support all families (civilians and military), and is nationally, publicly available free of charge both virtually and real world. The booklet was created by a small team led by child & family Psychiatrist Dr. Doug Gray. Since its release, this resource has been recommended by agencies such as the Department of Education, Suicide Prevention Resource Center, and the American School Counselor Association.


“How to Talk to a Child about a Suicide Attempt In Your Family” aims to support parents and other caregivers who are challenged with comforting and/or explaining a loved one’s suicide attempt. The combination booklet/DVD (available free of charge, either virtually or in print) addresses four main challenges: demonstrating how speaking with a child about a suicide attempt is both necessary and beneficial; providing key strategies for meeting the needs of three developmental groups (Preschool, School Age, and Teen); offering tools to increase skill and comfort level with this delicate task; and, supplying further resources to better care for themselves as well as their family members. The 24-page booklet provides the basis, addressing critical issues such as mental illness, substance use, hopelessness and suicidal thoughts and behaviors, as well as building resiliency and restoring hope. The professionally produced video demonstrates these principles in action, and shows how real-life conversations might unfold. Free print copies of booklet and DVD are also available

Suicide prevention is a commonly used and understood term. However not everyone recognizes suicide postvention. Suicide postvention builds upon prevention efforts by providing immediate and ongoing support to those impacted by a suicide loss.
 
Postvention is critical for healing after suicide. Uniting for Suicide Postvention (USPV) provides resources and support for everyone touched by suicide loss.
Visit the USPV online resource hub to find support tailored for three audiences: community, providers and workplace.

Other clinician resources also available:
  • Clinical tools such as therapeutic risk management of the suicidal patient; self-directed violence classification system nomenclature; suicide risk assessment
  • Self-Directed Violence Classification System (SDVCS) nomenclature: tool & training
  • Assessment tools
  • Free lethal means safety training for any provider, including outside VA
  • Podcasts and videos: Some of the podcasts include Chain Analysis for Suicidal thoughts and Behaviors and Experiencing a Suicide Loss: Professional Caregivers
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Addressing patient stress during a pandemic: How physicians can help

6/4/2020

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BY TODD ARCHBOLD, LSW, MBA

Finding ways to balance the physical risks and emotional distress caused by COVID-19 is important for both health care personnel and patients. The mental health needs of entire communities are on the rise. The best practices that we are promoting to keep people safe from the virus are completely contrary to the practices we rely on to stay mentally well and emotionally resilient. “Social distancing,” the pillar of these efforts, has led to fear and isolation for many people. The reality is that COVID-19 is not a “social” disease at all, since it is transmitted by respiratory droplets among individuals who may have never had any social interaction. The inadvertent side effect of trying to keep physically safe through social distancing has in fact created emotional distress and removed us from the usual comforts of life and means of support. These necessary measures are our best defense in fighting infectious diseases, but many patients are now reporting an increase in emotional distress as a result.

Health care providers around the world are now tasked with providing exams and treatments to patients who are fearful of clinics and hospitals. In addition, the added stress of dealing with this pandemic is interfering with preventative visits, and the costs of care for patients dealing with comorbid conditions will likely increase even more. The challenge for our health systems and clinicians will be to provide necessary care while addressing the added complexity of the impact to the mental health of patients and providers alike.
Read full article here
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Childhood Specific Covid-19 Resources

6/4/2020

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  • Clear Coronavirus Answers for Kids
  • AACAP resources for families and children
  • NY times article with numerous hyperlinks to age appropriate books on Coronavirus
  • PBS Kids Videos for preschoolers about Corona and Hygiene
  • My Hero is You
  • Stress Management and teens
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'You deserve to celebrate': A doctor's advice for teens and parents during the pandemic

6/4/2020

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The rites of passage that often define childhood — summer camp, prom, tossing a mortarboard into the air at graduation — will look very different this year, if they happen at all. And that can have a profound impact on the mental health of young people. It's not just the loss of fun activities. They're missing out on experiences meant to “conclude one chapter in our life and start the next chapter,” said Dr. Joshua Stein. Read full article here
- by PAL Psychiatrist, Dr. Stein

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Twin Cities Live: How parents can manage stress during the Covid-19 Pandemic

6/4/2020

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Parents are taking on new roles as we social distance and schools are closed. This can be joyful but also overwhelming, exhausting and confusing at times. Parents now find themselves acting as parents, chefs, employees, teachers, and more. Adding Therapist to that list might be more than they can handle.

Many families, children and parents are feeling hopeless, helpless and worthless. Children may be more irritable, aggressive, somatic or despondent. Mental Health resources and PrairieCare remain open, essential and readily available. The relaxation of telehealth requirements allows rapid assessments and transitions to treatment from the comfort of your home.
 
Some beneficial suggestions from the American Academy of Child Adolescent Psychiatry:
  1. Try and establish a regular routine and schedule at home. Kids are reassured by structure and predictability.
  2. Give kids choices, where there are choices. You may not be able to visit friends or go to the movies, but you can pick which game to play or program to watch.
  3. Help kids keep in touch with friends and family members by phone, e-mail, FaceTime, Zoom, Skype, etc.
  4. If kids have questions about COVID-19 or about why you’re sheltering in place, answer them honestly, using words and concepts they can understand.
  5. Help children find accurate and up to date information. Print out Fact Sheets from the CDC, WHO or your local health authority.
  6. Don’t let children watch too much television with frightening images. The repetition of such scenes can be disturbing and confusing.
  7. Encourage kids to choose something new to learn about. It could be a game, a craft or a challenging book
  8. Make sure kids stay physically active. If you’re in a rural area, take a walk outside (observing social distancing guidelines). If you’re in a more urban setting, help your child develop and maintain a regular in-home exercise routine.
  9. Let kids participate in menu planning and meal preparation. Try and cook or bake something new.
  10. Be flexible…and patient. Sheltering in place may seem fun for the first few days, but the novelty quickly wears off. Your kids may not always feel like talking or doing what you’re doing.
  11. Be honest. Acknowledge that this is a difficult time for everyone. It’s normal to feel tense and anxious under such trying and unusual circumstances.
  12. Give kids space. Everyone needs some private “down time”.
  13. Let little things go. Try not to overreact when things break, take too long or don’t go quite as expected.
  14. Make future plans. Talk about and research things to do and places to go after the pandemic ends. 
 
Click for full video ​​

- PAL Psychiatrist: Josh Stein, MD


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Covid-19: Dealing with anxiety & how to help children and families during this time

6/4/2020

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PAL psychiatrist, Dr. Joshua Stein, joined Twin Cities Live this last week with ways to recognize anxiety and how families can manage symptoms during this pandemic.
 
How to recognize different levels of anxiety for you and your family
  • Children may present with body concerns, stomachaches, diarrhea, headaches, outbursts, meltdowns, challenging behaviors
  • Monitor levels of irritability
  • Excess alcohol consumption, changes with food consumption (eating more or eating less)
  • sleep issues
 
How do you know if it’s time to be concerned and seek professional help?
  • Warning signs: changes to sleep, decline in hygiene, profound irritability, “giving up”
  • Thoughts of self-harm or
  • Any suicidal thoughts of any kind
  • New sever conflict in a partner/spousal relationship
**If you are asking yourself this question let a professional help determine this
**The recent changes to telehealth allow rapid in home access
 
How do you stay informed without getting overwhelmed?
  • Choose a reputable news source
  • Set limits for consuming information (e.g., only read/watch newsources for 30 minutes 2x a day)
  • Focus on what you can control; i.e meals, exercise, next book
  • It is easy to slip into catastrophic ideas. This will happen. If it is interfering with parenting, please reach out
 
What kind of toll can it take on you to “be strong” for your family and how can that be managed?
  • Take time at the end of the day to “Emote/Sound Off” with another adult. i.e. partner/friend/coworker
  • Commonly we end the day at the TV; Instead make time to share struggle/grief/loss/laugh
  • Know that it is healthy and important for your kids to see you experiencing normal emotions sometimes
 
Is there anything you can do right now to help – unplugging from the news, taking a walk, etc.
  • Connectedness is important
  • Don’t’ just text. Facetime or call family, your children’s friends, teachers, coworkers
  • Let your child be the expert and teach you; learn about “Sound Cloud”, “fortnite”; “Roblox”; Learn a “Tik Tok” dance
  • Dance to “Koo Koo Kangaroo”, “Go Noodle” with your children. Have them share their favorite video
  • Create! Art, dominoes, a positive yard sign, school pride, face paint
  • It’s ok to relax rules. Many parents feel guilt about children and excess screen time. Let yourself off the hook
  • Get outside: Use your firepit; create a scavenger hunt, Build a Scooter Ramp; Use those Amazon boxes to build a fort
  • Cuddle
  • Take 5 minute mini-breaks to pause, breathe and focus upon gratitude
 
If you are a patient or family member or friend in need of immediate assistance:
  • Disaster Distress Helpline
  • Call 1-800-985-5990 or text TalkWithUs to 66746
  • National Suicide Prevention Lifeline
  • Call 800-273-8255 or Chat with Lifeline
  • Crisis Textline
  • Text TALK to 741741
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Minnesota's leading edge: creativity and collaboration

6/4/2020

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Our nation is amidst a mental health crisis. For the last decade we have seen an increase in the prevalence of psychiatric conditions, deaths from opioid overdoses, and suicide rates, coupled with a drastic increase in people with mental illness who are homeless or incarcerated. All too often, barriers to accessing care result in individuals and families enduring crisis and experiencing traumatic events that could have been prevented. We are also facing a substantial shortage of psychiatrists as well as access to inpatient beds and specialized psychiatric care. Studies demonstrate a public perception that mental illnesses are linked to dangerousness or violence. Funding strategies are constantly shifting at the federal and state levels, and the insurance reimbursement for psychiatrists is, on average, 21% less than for primary care physicians.

The grim reality is that our current approach to mental health care, shaped in the late 20th century, will not continue be effective today. Effective models for mental health care require radical change and transformation. Bruce Schwartz, MD, president of the American Psychiatric Association, stated recently that, “We have to marshal the entire workforce who cares for people with mental illness. That includes social workers, advanced practice nurses, psychologists, mental health counselors, and peer counselors. It comes down to collaboration and putting aside some of the guild issues about which we all have valid concerns.”

The local angle
Minnesota, on the other hand, has led the way with creative and collaborative new care models. Since the early 2000s, the state has consistently ranked among the top 10 states in health care, education, quality of life, cost of living, social welfare, entertainment—and in mental health. Even before the passage of the Affordable Care Act (ACA) in 2010, nearly 95% of Minnesotans had insurance coverage, and mental health parity was noticeably salient for residents. Today, more Minnesotans than ever have greater access to care, and more children and families are proactively seeking health care through annual check-ups and wellness visits.

​Creativity and collaboration have been key factors as Minnesota addresses our mental health crisis in various settings, including hospitals, schools, advocacy groups, and nonprofits. Initiatives to meaningfully manage mental health needs span the continuum of care: resiliency coaching, crisis prevention, trauma response, integrated care, and acute care. This includes service providers and new screening and diagnostic tools.

Prevention and wellness
Examples of Minnesota’s initiatives include Allina Health’s Penny George Institute—the largest integrative health center in a health system in the country—which focuses on holistic health and wellness. The University of Minnesota offers a bachelor’s degree program in Health and Wellbeing Sciences, as well as a graduate degree in Professional Studies of Integrated Behavioral Health. These educational programs, along with the investment into services and infrastructure, help Minnesotans prepare for the future; they are an invitation to change the way we currently react to mental illnesses and crisis, preparing us to prevent and better understand mental health.

Many more schools and community-based organizations have started programs that focus on mental well-being, resiliency, and peer support. Seventy percent of mental illnesses have an onset of symptoms before age 14. Programs that can help kids and parents identify these symptoms earlier can help prevent or lessen the potentially devastating impact that untreated mental illnesses can have on the academic and social development of youth. This can be done through screening, conversations with school staff, and breaking down the stigma that often prevents individuals from reaching out for help. Many local charities and non-profit organizations have supported schools in these endeavors through grants and in-kind access to professional mental health resources.

Employers have brought mental health resources, education, and support into the workplace. Studies show that nearly 63% of individuals with a diagnosed mental illness have not disclosed it to their employer. Ryan Companies’ Support without Stigma program allows for open conversation and sharing about mental health issues. Similarly, one large local retailer now hosts monthly educational events and has established a mental health ally program that allows employees to connect with peers who have gone through special training.
​
The Minnesota chapter of the National Alliance on Mental Illness has helped support funding for countless mental health programs, along with the ongoing development of new programs, such as school-linked mental health. When the state did face cuts and setbacks to mental health programs, NAMI Minnesota’s persistent and staunch advocacy remained intact. And in 2014, Healthpartners launched an award-winning anti-stigma campaign called MakeItOK that is supported by 11 local health systems, mental health providers, and media.

Integrated behavioral health
Many individuals in need of treatment for mental health and substance abuse disorders will never be identified in primary care—and, even if they are identified, will then have to rely on referrals to outside agencies. Less than 50% of these patients follow through on their referrals. In response, many health systems now offer onsite, integrated behavioral health services. This can reduce expenditures, since treating a medical condition can cost upwards of 200% more when an untreated mental health condition also exists.
South Lake Pediatrics, an independently operated and physician-owned medical group, has nourished a culture of listening closely to parents and kids to understand and identify signs of mental illnesses. They have partnered with behavioral health providers to integrate psychotherapy and psychiatry at their sites, allowing for easy referrals, increased communication, and optimized coordination of care. This model delivered a 28% increase in follow-through for initial referrals and a 10% decrease in no-show rates. Clinicians and patients have praised the ease of referrals and resulting quality of care.

Similarly, Ridgeview Medical Center has partnered with PrairieCare Medical Group to establish a jointly managed behavioral health division offering integrated outpatient care and inpatient consultations to their hospital. This partnership will offer expedited access to mental health care to thousands of individuals in the community, through coordination with primary care providers.

School-based innovations
Minnesota school systems—long revered as leaders—have often been the “canary in the coal mine,” the first ones to observe and experience changes in youth behavior and engagement. Starting in 2006, the Minnesota Department of Human Services (DHS) supported legislation to help fund school-linked mental health services aimed at reducing barriers to care and to promote early identification and intervention. Newer state-sponsored innovation grants continue to help identify new ideas and creative ways in which school districts can better support students whose academics and futures are jeopardized by unidentified or untreated mental illnesses.

Minnesota has three metro-based Intermediate School Districts with special designations that support integrated services in vocational education, special education, and, increasingly, in the area of mental health. Since summer 2018, five Intermediate School Innovation Grants were awarded with the goal of improving clinical outcomes for students, helping them return to their home school district, reversing the disproportionate impact on students of color, and providing support and training for school staff and parents. Intermediate School District #287 has prioritized funding strategies to have board-certified child and adolescent psychiatrists onsite to integrate care with the families and learning teams. The shortage of these specialists, along with the barriers in accessing care, would otherwise mean that many of these youth in need would likely never receive the care required.

Some schools have even built health clinics on-campus. Brooklyn Center schools offer wellness visits, vaccinations, and mental health counseling. Minnesota Community Care operates clinics in nine St. Paul public high schools, providing mental health case management as well as trauma-focused cognitive behavioral therapy (TF-CBT) therapists. A new grant extension of these programs now includes federal funding to pilot onsite psychiatry.

Statewide psychiatric consultation
In 2010, the Minnesota Legislature directed DHS to make psychiatric consultation available statewide to primary care providers. The goal was to create rapid access to psychiatrists for consultation on cases, triage, and referral, and to provide ongoing education to primary care providers. Nearly half of the states in the nation have some form of a psychiatric consultation service, ranging from telephonic consults to brick-and-mortar clinics based in academic medical centers. Minnesota’s Psychiatric Assistance Line (PAL) has provided thousands of consultations to primary care providers across the state, and has trained hundreds of pediatricians and nurse practitioners. PAL can be accessed weekdays via a toll-free number or online. This service is supported by DHS, PrairieCare Medical Group, and the Minnesota Community Mental Health Foundation. In addition to the core clinical team members at PAL, clinicians at Pregnancy & Postpartum Support Minnesota are available for mothers who have specific needs requiring their expertise.

Most of the consultations are with youth, who otherwise would endure delays in getting specialized treatment and suffer from the adverse developmental impact that mental illnesses can have during childhood. A six-month follow-up study confirmed PAL’s efficacy and the overall positive experience of the providers, individuals, and families that utilized it. The psychiatric consultation service was recently honored by the American Psychiatric Association (APA) and the Association of Medicine and Psychiatry (AMP). Several other states and outstate health systems continue to express interest in partnering with PAL.
​
In addition to psychiatric consultation and education, an online tool called the Fast-Tracker was developed to link people to mental health and substance use disorder services and resources with real time availability. This online tool, which is free to the public, uses sophisticated search tools and algorithms to help identify niche services for individuals seeking care.

Future considerations and improvements
While creativity and collaboration have made Minnesota a leader, there are still critical needs that require attention. It has been said that our mental health system is not broken, because it has yet to be built. The aforementioned innovations have helped many patients, but are just a part of the necessary transformation, which still needs to grow and adapt to future needs.

While the ACA and mental health parity have moved us forward in some ways, concerning trends in the behavior of many health insurance companies suggest that adequate coverage for services is still in our distant future. High-deductible plans have become more popular, and large employers have elected to carve out mental and chemical health coverage to lower premiums, perpetuating both barriers in accessing care and the stigma surrounding mental illnesses. Many individuals and families are simply finding themselves under-insured.

Communication between health providers continues to lag, especially with regard to mental health. While electronic health records allow for the possibly of a seamless community, expensive integrations between systems often prohibit this from happening, and release of information and consent laws create confusion around what information is released. Some patients may bounce between several providers, and the refusal to disclose past mental health information can be common and detrimental to care.

Minnesota is indeed a leader in mental health care, as we have continued to demonstrate through our creativity and collaboration. However, we have a long journey ahead of us, and we must have the perseverance and gumption required to move our local communities and the rest of the nation forward.

Todd Archbold, LSW, MBA, is a licensed social worker and the chief executive officer at PrairieCare. 

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Means Reduction: Removing the HOW people commit suicide

1/6/2020

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Written by Joshua Stein, MD

A common difficulty in the outpatient office is determining the steps needed to ensure the safety of a patient once they identify that they are suicidal. There are two known methods to ensure safety; mental health treatment at the appropriate level of care and means reduction. The need to determine level of care will be examined in a future post. The significant importance of the removal of means to suicide, or Means Reduction, is the focus of this article.

A common myth is that a suicidal person, who has identified a source for completion, will substitute an alternative method if his/her original method is taken away. This belief in almost all settings represents a fallacy. The lethal means, whether overdose, a firearm, a one car crash etc, will not be substituted for another. 

Given the opportunity, the removal of chosen lethal means, especially firearms, will greatly reduce the How people attempt: leading to time to determine the Why, and introduce treatment.

​Per NAMI, there are numerous examples from history where the removal of a lethal means has decreased the death rate. In 1960, lethal oven gas ingestion was the leading cause suicides in the UK. By 1970, the country had substituted non-poisonous gas, resulting in a one third decrease in the suicide rate. The entirety of the drop stemmed from the change in gas, and non-gas related suicides had only increased slightly. The entirety of the change stemmed from means reduction to lethal gas.

The Israeli Defense Force (IDF) struggled significantly with suicides off base on vacations and weekends. In 2006 soldiers were no longer allowed to carry firearms off base for breaks. The suicide rate dropped approximately 40 % with no change in the rate of suicides during the week. The entirety of the change appeared to be related to the means reduction to firearms off base.
Numerous studies demonstrate that the acute action phase towards suicide is commonly brief. By removing the means to attempt, people often reach a plateau of safety when support can be introduced. The most common method of suicide attempt is by intentional overdose. The most likely lethal attempt is by firearm. Practical steps are outlined below:
  1. If a means is shared, it must be removed (substitutions are not likely)
  2. Additional means to suicide should also be removed to improve safety
  3. Remove all firearms
  4. Lockup medications, including OTC (carry in car if needed)
  5. Remove car keys
  6. Remove Sharp objects/knives
  7. Remove cords and ropes
  8. Remove alcohol
  9. Identify a family member or friend who can remove the means before a patient returns home
  10. Have the person who is removing the means alert the treatment team by phone call that this has been completed
  11. Document this step

At times, resistance to removing the means may occur from a friend/family member. A common desire to increase the difficulty of the attempt often is a practical point to reach agreement. As these are common objects in the home and firearms carry significant value, there is a time at which reintroduction should occur. Similar to the safety assessment in the medical office that led to removal of means, a safety assessment can take place to approve returning these objects to the home.

​In conclusion, removal of the means works in significantly improving safety. If a patient is deemed appropriate to return home, whether from a hospitalization or an outpatient appointment, steps towards means reduction need to take place. Finally, when a patient identifies a means, action should be taken, the fallacy to believe an alternative means will be substituted is incorrect.

SOURCES:
  • NAMI MEANS REDUCTION LECTURE
  • Shaffer D, Pfeffer CR, & the Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. JAACAP. 2001;40(7 Supplement):24S-51S.
  • Shain BN. Suicide and suicide attempts in adolescents. Pediatrics. 2007;120(3):669-675.
  • American Association of Suicidology. Youth Suicide Fact Sheet. January 28, 2008. Available at: http://suicidology.org/c/document_library/get_file?folderId=232&name=DLFE-24.pdf. Accessed April 19, 2009.
  • American Psychiatric Association. Let’s Talk Facts About Teen Suicide. Available at: http://healthyminds.org/factsheets/LTF-TeenSuicide.pdf. Accessed April 19, 2009.
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