xxAACP Newsletter, Volume 13, Number 3, Summer 1999
Regional Report:
Pennsylvania
Psychiatry has undergone tremendous changes and advances over the past decade and the Pennsylvania public mental health system has attempted to be quick in its response to the needs and the psychiatric treatment of persons with serious and persistent mentally illness. Clozapine received FDA approval in 1990 and after some initial concerns regarding the lethality due to associated agranulocytosis, it has now been made widely available to the people of Pennsylvania. As a hospital system (with approximately 3200 inpatients) there has been a sense that the drug is underutilized and there are similar concerns in the outpatient settings. The Office of Mental Health and Substance Abuse Services (OMHSAS) continues to encourage the appropriate use of this effective second line antipsychotic in refractory individuals. The introduction of olanzapine, risperidone and quitiapine has also had a tremendous impact on the system. Despite the significant increase in acquisition cost for these drugs, Pennsylvania been fairly progressive in making them widely available without significant restrictions. Even more importantly, it has done so without "fail first" mandates.
The combination of the above atypicals has a profound impact on the state hospital system allowing many patients to be discharged and has had a direct impact on bed reduction and hospital downsizing. They have also allowed our system to move to a rehabilitation and recovery model like never before because the patients are much more capable of taking advantage of rehabilitation services. The anti-aggressive qualities of these drugs along with improved performance measurement has resulted in a dramatic decline in the use of seclusion and restraint in the hospitals. This has been a priority of the system and the initiatives taken in the state hospital system have been held up as examples of what is possible in reducing or eliminating the use of these restrictive measures across the country.
Currently OMHSAS is actively working on defining the role of psychiatrists in the community mental health system. AACP member Ken Thompson, MD, is part of a workgroup with several other psychiatrists, organized to identify "best practice models" of community mental health and develop consistency of medical leadership in the outpatient setting. A major initiative within the office of the medical director is the education of practicing psychiatrists in the principles and value of psychiatric rehabilitation to improve their ability to know when to "prescribe" it for a patient, much as an orthopedist would prescribe physical therapy for a patient recovering from a broken bone or torn ligament. The lack of psychiatric involvement in psychiatric rehabilitation programs has been a major concern. The appropriate training of psychiatrists in the use of this effective modality is an ongoing challenge.
"Health Choices", Pennsylvania’s Medicaid managed care program has a behavioral health carve out and has recently expanded from the Philadelphia metropolitan area where it has been in effect for nearly two years, to Pittsburgh and its surrounding counties. Enrollment for Medicaid recipients became mandatory in the southwestern region as of July 1,1999. Both of these major urban centers have selected local nonprofit options for the management of behavioral health, and their success may well have significant implications in other parts of the nation as other states consider Medicaid managed care options.
Steven Karp, DO
Medical Director, OMHSAS
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