Stephen Barlas

The introduction of a House mental health parity bill in March has scrambled prospects for congressional passage of a bill that President Bush could sign. The introduction of the Paul Wellstone Mental Health and Addiction Equity Act (HR 1424) by Reps Patrick J. Kennedy (D, RI) and Jim Ramstad (R, Minn) threatens to split both the mental health community and the House and Senate.

The FDA finds itself straddling a data divide as it decides how to rewrite the black box warnings on the labels of SSRI antidepressants. The agency will almost certainly mandate that the existing black box warning, which addresses suicidality in children and adolescents, be expanded to include young adults up to age 25 or 30. But in what might be a pioneering move for the FDA, the agency will probably also include new verbiage in the warning related to the benefits of antidepressants to people over the age of 30 years.

The price and availability of psychiatric drugs is expected to be one of the major issues as Congress decides whether to try to find a way to force pharmaceutical manufacturers to lower the prices they charge Medicare Part D drug plans. Antidepressants, antipsychotics, and anticonvulsants are among the 6 categories for which Part D formularies must make available "all or substantially all" medications. As a result, the formularies are unable to bring to bear the drug price reduction strategies they use in other categories.

Just before it left Washington at the tail end of the December lame-duck session, Congress gave physicians a last-minute reprieve from the 5% Medicare pay cut that would have gone into effect on January 1, 2007. Moreover, the House and Senate approved a 1.5% bonus to be added to Medicare reimbursement in the second half of 2007 for physicians who voluntarily report quality-of-care measures.

Upcoming recommendations from a bipartisan presidential commission on possible long-term changes in the Medicaid program have mental health advocates sitting on the edge of their seats.

The Centers for Medicare and Medicaid Services (CMS) wants to again cut its payment to hospitals and community mental health centers (CMHCs) for outpatient psychiatric care in 2007. The benefit on which the CMS is focusing is called partial hospitalization; it is paid to a facility for treatment of a patient recovering from an acute psychiatric episode. Physicians must certify that in the absence of treatment in the partial hospitalization program (PHP), a patient would require inpatient psychiatric care. Typically, patients in a PHP spend 4 to 8 hours a day, 4 days a week, receiving intensive outpatient psychiatric care.

A report issued in September by the Department of Justice citing the prevalence of mental health problems among prisoners in federal and state prisons and local jails was called “an indictment of the nation's mental health care system” by Michael J. Fitzpatrick, MSW, executive director, National Alliance on Mental Illness.

Concerns about senior suicide and the lack of geriatric mental health services took center stage at hearings in the Senate Special Committee on Aging on September 14. Geriatric psychiatrists reviewed unfavorable trends such as faltering numbers of medical school graduates going into primary care and already small numbers of geriatric psychiatrists getting even smaller.

Nothing better reflects the difficulties of finding silver bullets for depression treatment than the results of the nearly completed Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, the largest clinical trial of its kind. With results imminent from the last of 4 trials in the study, psychiatrists are hoping for considerably more clinical guidance than what the first 3 levels of the trials produced.

In its latest report on medication errors, a committee assembled by the Institute of Medicine (IOM) included some sidebars on psychiatric drugs. The report, issued in July, said that there is too little data on misadministration of psychiatric drugs and that clinical trials with psychiatric drugs have been small and incapable of providing pragmatic, comparative information.

Chances appear good that Congress will once again veto a threatened cut in Medicare physician payments for calendar 2007--cuts that would cost psychiatrists an average of 7% in their billings.

There will be some major changes in the Medicare fee schedule for 2007. While psychiatrists are apt to make out better than some other subspecialties, it is unclear whether total payments for psychiatrists will go up or down.

Having lost a few battles over state laws allowing psychologists to prescribe drugs in some cases, organized psychiatry is trying a new tactic--this time at the national level--in order to define professional boundaries in scientifically appropriate ways.

Questions concerning the adequacy of mental health care for returning Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans continue to capture congressional attention. The latest reminder was a Government Accounting Office (GAO) report issued in May stating that of the 5 percent of returning veterans between 2001 and 2004 who tested as being at risk for posttraumatic stress disorder (PTSD), only 2 percent were referred by Department of Defense (DOD) health care providers for further mental health or combat/operational stress reaction evaluations.

A House committee is seeking to prohibit FDA members who have a financial interest in a company proposing a new drug (or in its competitors) from voting on new drug approvals from that company.

The use of psychiatric medications in children, including antidepressants (such as selective serotonin reuptake inhibitors) and drugs used to manage attention-deficit/hyperactivity disorder, are continuing to be reviewed by the FDA.

HR 4157, which would establish a federal patient information privacy standard that would pre-empt State patient privacy laws, is being rethought by one of its Congressional cosponsors.

A second opinion on the need for new warnings on attention deficit hyperactivity disorder (ADHD) drugs from the FDA advisory committee contradicts The Pediatric Advisory Committee recommendation.

The fiscal 2007 budget that PresidentBush proposed in early February keepsa tight lid on most domestic spendingprograms, including those at the Centersfor Mental Health Services (CMHS)and the National Institute of MentalHealth (NIMH). Budgets for both willactually decrease for the second yearin a row unless Congress steps in.

Congress agreed in December to drop from its consideration of a budget reconciliation bill a provision that would have allowed family therapists and counselors to bill Medicare for mental health diagnoses. Many psychiatrists viewed the proposed legislation as a scope-of-practice attack by non-MDs.

An Illinois draft plan to screen children and pregnant women for mental illness has stirred controversy and raised questions about some elements of the President's New Freedom Commission on Mental Health report. Some critics fear the Illinois case sets a worrying precedent for mental health care throughout the United States.

The Council of State Governments argues that police should be better trained to deal with mentally ill offenders. Increased funding is being requested in Congress to support educational programs for law enforcement.

Is the Office of the Inspector General unfairly targeting psychiatrists? The OIG recently reported negative findings for Medicare claims filed by psychiatrists. Will it continue to do so in the study planned for this year?

Restraint rules for young people are filled with troublesome provisions. The Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration) want to change some of the restraint use rules that apply to Medicaid residential facilities for patients under the age of 21.

Is consent necessary for medical records to be utilized for treatment, payment and health care operations? The medical records privacy rule demands it. Will prepayment and postpayment audits by insurance companies be cut back? The Medicare Education and Regulatory Fairness Act of 2001 is an attempt to solve this and other issues.

A leader of a key mental illness patient advocacy group indirectly but pointedly criticized psychiatrists for the care they give schizophrenics. Laurie Flynn, the executive director of the National Alliance for the Mentally Ill (NAMI), said she was "appalled" by the results of face-to-face interviews with over 700 schizophrenics during a 16-month period. The interviews turned up evidence of under- and overdosing of patients and a failure to get patients into effective community treatment plans.