It Takes Actual Corrective Action to Make Amends

via: MEDICAID MEDICAL DIRECTORS LEARNING NETWORK  

Antipsychotic Medication Use in Medicaid Children and Adolescents: A Study of 16 State Programs Spring 2011 Newsletter Update

"Washington State recently used the 16-State study to help move legislation (HB5892) on “generics first,” including antipsychotic medications, as well as more controls on off label use. The study helped build trust in generics to help support the legislation.  Washington Medicaid recently received a grant from the State Office of the Attorney General to review adult use of mental health medications in a statewide collaborative that includes red flags and feedback reporting on antipsychotic medications poly-pharmacy, dose, and medication adherence.  This effort will be part of the larger Rutgers study."

The above is a red herring it seems to me in all reality.  None of the cheaper older neuroleptics are on the Washington State "preferred list" for Medicaid or Medicare clients.  Only the new more expensive ones are---generic or Brand Name is not the only factor which effect the Medicaid budget.  The multiple drug studies done in adult and youth have effectively demonstrated that the newer more expensive drugs are not more efficacious or safer, only more expensive.  Why is this it not a priority to incorporate valid findings of very costly research?  Let me guess the decision is not based on sound decision making or valid clinical trial results.  The grant from the Attorney General to review the use of neuroleptic drugs is just plain strange.  Psychiatrists are using Police Officers as mental health paraprofessionals and the Superior Court as a psychiatric treatment compliance tool.  How have Officers of the Court been effectively recruited to deprive individual's of their Liberty and their Individual Rights to Substantive and Procedural Due Process?

From the American Academy of Child and Adolescent Psychiatry: 

Position Statement on Psychiatric Drug use for Children in State Custody 

AACAP Position Statement on Oversight of Psychotropic Medication Use for Children in State Custody: 

A Best Principles Guideline

Background 

Children in state custody (definition of state custody: the state has assumed all parental responsibilities and decision-making for the child) often have biological, psychological, and social risk factors that predispose them to emotional and behavioral disturbances.  These risk factors can include genetic predisposition, in utero exposure to substances of abuse, medical illnesses, cognitive deficits, a history of abuse and neglect, disrupted attachments, and multiple placements.

Resources for assessing and treating these children are often lacking.  Due to multiple placements, medical and psychiatric care is frequently fragmented.  These factors present profound challenges to providing high quality mental health care to this unique population.  Unlike mentally ill children from intact families, these children often have no consistent interested party to provide informed consent for their treatment, to coordinate treatment planning and clinical care, or to provide longitudinal oversight of their treatment.  The
state has a duty to perform this protective role for children in state custody.  However, the state must also take care not to reduce access to needed and appropriate services.

Many children in state custody benefit from psychotropic medications as part of a comprehensive mental health treatment plan. However, as a result of several highly publicized cases of questionable inappropriate prescribing, treating youth in state custody with psychopharmacological agents has come under increasingly intense scrutiny.  Consequently, many states have implemented consent, authorization, and monitoring procedures for the use of psychotropic medications for children in state custody.  These policies often have unintended consequences such as delaying provision of or reducing access to necessary medical care.

Basic Principles 

 The AACAP is the organization representing professionals most skilled in the art and science of child psychopharmacology.  Accordingly, the AACAP has developed the following basic principles regarding the psychiatric and pharmacologic treatment of children in state custody:
1. Every youth in state custody should be screened and monitored for emotional and/or behavioral disorders.  Youth with apparent emotional disturbances should have a comprehensive psychiatric evaluation.  If indicated, a biopsychosocial treatment plan should be developed.
2. Youth in state custody who require mental health services are entitled to continuity of care, effective case management, and longitudinal treatment planning.
3. Youth in state custody should have access to effective psychosocial, psychotherapeutic, and behavioral treatments, and, when indicated, pharmacotherapy.
4. Psychiatric treatment of children and adolescents requires a rational consent procedure. This is a two-staged process involving informed consent provided by a person or agency authorized by the state to act in loco parentis and assent from the youth.
5. Effective medication management requires careful identification of target symptoms at baseline, monitoring response to treatment, and screening for adverse effects.
6. States developing authorization and monitoring procedures for the use of psychotropic medications for youth in state custody should use the principles in this document as a guide and should assure that children and adolescents in state custody get the pharmacological treatment they need in a timely manner.

Best Principles Guideline 

 For states planning to develop programs for monitoring pharmacotherapy for youth in state custody with severe emotional disturbances, the AACAP proposes the following guidelines. Guidelines are categorized into minimal, recommended, and ideal standards.
1. State child welfare agencies, the juvenile court, or other state or county agencies empowered by law to consent for treatment with psychotropic medications, in consultation with child and adolescent psychiatrists, should establish policies and procedures to guide the psychotropic medication management of youth in state custody.
States should:
a) Identify the parties empowered to consent for treatment for youth in state custody in a timely fashion [minimal].
b) Establish a mechanism to obtain assent for psychotropic medication management from minors when possible [minimal].
c) Obtain simply written psychoeducational materials and medication information sheets to facilitate the consent process [recommended].
d) Establish training requirements for child welfare, court personnel and/or foster parents to help them become more effective advocates for children and adolescents in their custody [ideal]. This training should include the names and indications for use of commonly prescribed psychotropic medications, monitoring for medication effectiveness and side effects, and maintaining medication logs.

Materials for this training should include a written “Guide to Psychotropic Medications” that includes many of the basic guidelines reviewed in the psychotropic medication training curriculum.

2. State child welfare agencies, the juvenile court, or other state or county agencies empowered by law to consent for treatment with psychotropic medications, in consultation with child and adolescent psychiatrist, should design and implement effective oversight procedures that:
a) Establish guidelines for the use of psychotropic medications for youth in state custody [minimal].
b) Establish a program, administered by child and adolescent psychiatrists, to oversee the utilization of medications for youth in state custody [ideal].

This program would: 

i. Establish an advisory committee (composed of agency and community child and adolescent psychiatrists, pediatricians, other mental health providers, consulting clinical pharmacists, family advocates or parents,
and state child advocates) to oversee a medication formulary and provide medication monitoring guidelines to practitioners who treat children in the child welfare system.
ii. Monitor the rate and types of psychotropic medication usage and the rate of adverse reactions among youth in state custody.
iii. Establish a process to review non-standard, unusual, and/or experimental psychiatric interventions with children who are in state custody.
iv. Collect and analyze data and make quarterly reports to the state or county child welfare agency regarding the rates and types of psychotropic medication use.  Make this data available to clinicians in the state to improve the quality of care provided.
c) Maintain an ongoing record of diagnoses, height and weight, allergies, medical history, ongoing medical problem list, psychotropic medications, and adverse medication reactions that are easily available to treating clinicians 24 hours a day [recommended].
3. State child welfare agencies, the juvenile court, or other state or county agencies empowered by law to consent for treatment with psychotropic medications, should design a consultation program administered by child and adolescent psychiatrists [recommended].

The consultation program:

a) Provides consultation by child and adolescent psychiatrists to the persons or agency that is responsible for consenting for treatment with psychotropic medications.
b) Provides consultations by child and adolescent psychiatrists to, and at the request of, physicians treating this difficult patient population.
c) Conducts face-to-face evaluations of youth by child and adolescent psychiatrists at the request of the child welfare agency, the juvenile court, or other state or county agencies empowered by law to consent for treatment with psychotropic medications when concerns have been raised about the pharmacological regimen.

4. State child welfare agencies, the juvenile court, or other state or county agencies empowered by law to consent for treatment with psychotropic medications, should create a website to provide ready access for clinicians, foster parents, and other caregivers to pertinent policies and procedures governing psychotropic medication management, psychoeducational materials about psychotropic medications, consent forms, adverse effect rating forms, reports on prescription patterns for psychotropic medications, and links to helpful, accurate, and ethical websites about child and adolescent psychiatric diagnoses and psychotropic medications [ideal]  (emphasis mine)

 My take on this "plan"

 My primary problem with this whole thing is this plan is needed due to the lack of ethics of psychiatrists, academic researchers and KOLs who have made exaggerated claims about the safety and the efficacy of psychotropic drugs, while minimizing, or hiding altogether the dangers.   Now the very people who pushed for using psychotropic drugs so indiscriminately on children with symptoms of distress or who are experiencing emotional and/or behavioral difficulties; are suggesting they need to  'monitor' the drugging and counsel others how to more effectively use the protocols they developed.

"We can't solve problems by using the same kind of thinking we used when we created them."

Albert Einstein

I see no evidence of accountability, nor any personal responsibility individually or collectively for the  gross errors of judgement, recommending the new much more expensive drugs, and implementing treatment Standard Practices based on subjective opinions, without valid empirical data to support them.  

What kind of "ethics" or "medical judgement" would enable a professional to lie to other medical professionals, in training seminars, lie to patients and their parents, publish biased and incomplete results which do not accurately reflect clinical trial data in "peer-reviewed" journals and College Textbooks?  In spite of this known reality, we are supposed to believe that fixing this mess can be trusted to the same unethical professionals who created it, and that having these 'professionals' 'MONITOR the other medical professionals they led astray themselves?!   Forgive me, why would the architects of a massive financial and medical fraud delude themselves that into believing that the solution is Monitoring the ongoing medical malpractice and Medicaid Fraud which uses teratogenic drugs which cause can cause iatrogenic illnesses and serious disabilities and even death, on vulnerable cognitively, physical normal children?  Why should we believe the perpetrators are trustworthy or responsible enough to fix the mess they have made?  There is no evidence of any accountability for the harm caused to patients; no responsibility for the Medicaid fraud that resulted from adopting drug treatment algorithms in which dangerous drugs not approved for use in children.  In effect, these treatment algorithms and Practice Parameters for diagnosing and treating various psychiatric diagnoses in children amount to off label marketing of the drugs for the pharmaceutical manufacturers!

The rate of psychiatric delusions of grandeur must be epidemic.  These professionals believe that their record of mistreatment of human beings who are in distress, has done nothing to undermine their credibility.  I know that I am not the only parent who is less than grateful for the "treatment" that unethical psychiatrists inflicted upon my youngest son.  I have a great deal of fear of further harm being done to him; he is terrified to go to a type of medical clinic or hospital.  Thank God he trusts me.  I know that my ability to protect him and advocate for him is severely limited by the Unconstitutional Laws and public policies which are part of the mass marketing campaign for psychiatric drugs.  Members of the APA, the AACAP,  TAC  and NAMI and BigPharma acted  in collusion as "advocates for the mentally ill" implementing public policy so the primary beneficiaries of their collective efforts are the drug companies.  The drug companies continue to profit, and continue to commit fraud, and psychiatric patients are continuing to be harmed, disabled and killed.  Their socalled 'advocates' remain silent about their plight.

Human beings who are already disabled by psychiatry's treatment guidelines and standard practices developed by a quasi-democratic process the same method used to develop the diagnoses.   The system developed to classify humans "mentally ill" and "treat" them also does not value Informed Consent so accurate, ethical information about the diagnoses or the drugs, is unnecessary.  Imagine being a parent who is betrayed by psychiatrists and who is aware that due to misplaced trust, and abuse of power and authority, you were unable to effectively protect your own child who is now disabled.  I live with this reality.  I know that we are lucky too, because my son is alive; and I cling to the belief that where there is life, there is hope.

These "doctors" have earned no trust, but demand respect and imply they are trustworthy.  These doctors have corrupted the scientific evidence base thoroughly, if not completely.  These pseudo-professionals relied on the honor and integrity that often inspires unquestioning blind trust from patients who are suffering.  These 'doctors' have smeared a noble profession, and have caused unwitting colleagues in the medical professions to harm their own patients by misinforming them about the drugs!   Relying on unearned esteem and at one time,  unquestioned medical integrity, these doctors failed to practice their craft according to the precepts a healer holds dear:  respect for the patient is paramount, and the care must be for the patient's potential benefit; not for the doctor.  It is supposed to be an honor to attend to people whose suffering has brought them to your door.  To always and forever remember, that as a physician, one has a duty to, "First, do no harm..."

Individually, and collectively, Key Opinion Leaders, Leading Psychiatric Researchers and Academics who are members of  the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry have taught students of psychiatry, and other medical specialties biased bullshit which has caused them to harm countless thousands of human beings; because they did not realize what they were being taught was not based on scientific evidence.  They had no idea that the "medical advice" they were relying on was not complete, accurate or truthful.  The above proposed guideline shows a lack of insight and hubris.  It is written by a professional who implies that the very people who caused this crisis, can effectively stop the ongoing damage done to psychiatry's victims by MONITORING the ongoing off label prescribing of teratogenic drugs to our children!  To continue to advise other professionals how to continue to use the tools which have caused the problem in the first place!  It is the height of arrogance, and is utterly irresponsible. 

The widespread adoption of a pill for every ill, even if the pills can kill; is based on biased and incomplete information, that is still being used!  Key Opinion Leaders who are also Research and Academic 'scholars' published this crap in journals and textbooks.  This "science" is supposedly what was used to develop treatment algorithms, practice parameters, and standard clinical practice guidelines, to assist other clinicians yet each and every KOL, claims they have no idea why their expertise is actually being relied  the or WHY the drugs are being widely prescribed.  Such protestations are either an outright lie, or evidence of a group delusion.   I would bet it is the former, since prevarication has been pervasive in psychiatry.

My thoughts about the AACAP's final recommendation.  "State child welfare agencies, the juvenile court, or other state or county agencies empowered by law to consent for treatment with psychotropic medications, should create a website to provide ready access for clinicians, foster parents, and other caregivers to pertinent policies and procedures governing psychotropic medication management, psychoeducational materials about psychotropic medications, consent forms, adverse effect rating forms, reports on prescription patterns for psychotropic medications, and links to helpful, accurate, and ethical websites about child and adolescent psychiatric diagnoses and psychotropic medications [ideal]"  The fact that it needs to be stated by this professional group in this document, is very telling.  Stating the obvious at the end of this guideline for "best principles," when the ideas contained are the foundation of honest, academic inquiry and critical to providing ethical medical care.  The fact that it is on this document is an acknowledgement that these conditions have heretofore been ABSENT.   It is sad and truly ironic.

The fact is, patients, other medical professionals and the general public who have paid the heavy costs emotionally, physically, financially and socially for the AACAP's utter failure to provide accurate, and ethical information about psychiatric diagnoses and psychotropic medications, really need for the these professionals to make actual, meaningful amends for their egregious ethical, moral, medical and legal failures---and stop trying to deny responsibility for the harm they are continuing to cause by failing to do so!

It is time to show that the world if members of the APA and ACAAP are professionals worthy of being granted an opportunity to regain the trust their actions destroyed; it is way past time to stop pretending that they still have it.   Acting superior and claiming authority you do not have, while still denying responsibility for the harm these professionals individually and collectively have caused is not going to regain either trust or credibility!  Psychiatry as a profession will regain no trust and restore any integrity without acting honorably.  Psychiatrists individually and collectively will not regain lost trust or respect without actually making restitution morally; this requires changing how psychiatrists individually and collectively conduct themselves.

It means holding patients in positive regard, being honest, forthright and accountable; it means no longer turning a blind eye to unethical, harmful and fraudulent conduct in research or in clinical practice, by holding individuals accountable.  The behaviors which were committed by the relative few among you, have caused the profession's loss of trust; however, it is the many who have in fact allowed it to continue to cause harm to patients and to the integrity of the profession.

I am skeptical, due to too many negative experiences, and my once high regard for psychiatry is now,  nonexistent.  I do not believe that most psychiatrists have the humility, the integrity or the self-will required to make the amends needed.  I suspect some may be too arrogant to consider it; much less even comprehend why it may be necessary to earn their patients and the public's trust.  I wonder do these KOLs and Lead Researchers understand that without honesty, true integrity doesn't exist at all?

I doubt that the writers of this guideline stopped to consider this last suggestion would, if sincere were acted upon it would require that psychiatrists stop directing people to seek information on the National Institutes of Mental Health, National Alliance on Mental Illness, the American Psychiatric Association or the American Academy of Child and Adolescent Psychiatry's websites?

Unless the AACAP actually isn't serious about this Best Principles Guideline, and it is just a cover their ass move to look like they are concerned at the effect of fraudulent reporting of drug safety and efficacy and their pill for every behavioral or emotional ill approach for children, without using reason, logic, even the information that is valid, accurate and available.  Perhaps the AACAP does plan to remove the inaccurate and unethical information about psychiatric diagnoses and psychotropic drugs from it's own website; and to convince the other organizations to do the same...

State Government, and Juvenile Justice and Social Service providers refer people to NAMI---I myself, a handful of months ago was AGAIN asked if I had contacted this group for assistance---the suggestion is laughable; but it is not at all humorous...

It would be a sign the AACAP's sincerity if in a show of good faith, it was to do some major overhauling of their own website, and retract the biased and outright falsely reported research in their "peer-reviewed" Journal (STUDY 329?!) Doing so would demonstrate a commitment to only using "accurate, and ethical information" as this guideline suggests...

I'm not holding my breath though...   

It remains to be seen whether the Quack Masters will continue to follow their creed or begin to follow ethical scientific and medical principles they have heretofore ignored altogether...