Yasuhiro Kishi

General Medical and Pharmacy Claims Expenditures in Users of Behavioral Health Services

OBJECTIVE: To quantify the magnitude of general medical and/or pharmacy claims expenditures for individuals who use behavioral health services and to assess future claims when behavioral service use persists.DESIGN: Retrospective cost trends and 24-month cohort analyses.SETTING: A Midwest health plan.PARTICIPANTS: Over 250,000 health plan enrollees during 2000 and 2001.MEASUREMENTS: Claims expenditures for behavioral health services, general medical services, and prescription medications.MAIN RESULTS: Just over one tenth of enrollees (10.7%) in 2001 had at least 1 behavioral health claim and accounted for 21.4% of total general medical, behavioral health, and pharmacy claims expenditures. Costs for enrollees who used behavioral health services were double that for enrollees who did not use such services. Almost 80% of health care costs were for general medical services and medications, two thirds of which were not psychotropics. Total claims expenditures in enrollees with claims for both substance use and mental disorders in 2000 were 4 times that of those with general medical and/or pharmacy claims only. These expenditures returned to within 15% of nonbehavioral health service user levels in 2001 when clinical need for behavioral health services was no longer required but increased by another 37% between 2000 and 2001 when both chemical dependence and mental health service needs persisted.CONCLUSIONS: The majority of total claims expenditures in patients who utilize behavioral health services are for medical, not behavioral, health benefits. Continued service use is associated with persistently elevated total general medical and pharmacy care costs. These findings call for studies that better delineate: 1) the interaction of general medical, pharmacy, and behavioral health service use and 2) clinical and/or administrative approaches that reverse the high use of general medical resources in behavioral health patients.

Schizophrenia and narcolepsy: A review with a case report

Abstract  Several reports emphasize the importance of differentiating between psychosis in schizophrenia and the psychotic form of narcolepsy. The failure to identify narcolepsy leads to the labeling of patients as refractory to standard treatments for schizophrenia and retards consideration of intervention for narcolepsy in which psychosis can improve with psychostimulant treatment. Psychosis in patients with narcolepsy can occur in three ways: (i) as the psychotic form of narcolepsy with hypnagogic and hypnopompic hallucinations; (ii) as a result of psychostimulant use in a patient with narcolepsy; and (iii) as the concurrent psychosis of schizophrenia in a patient with narcolepsy. The present case report describes a difficult‐to‐treat patient who likely had concurrent schizophrenia and narcolepsy. It then summarizes the literature related to the treatment of the three types of patients with psychosis associated with narcolepsy.

Misdiagnosed Delirium in Patient Referrals to a University-Based Hospital Psychiatry Department

The authors examined the factors associated with referral errors in which the presence of delirium was ostensibly not recognized by medical staff personnel. Medical records of 541 university-hospital patients consecutively referred for psychiatric consultation were scrutinized for extant delirium. The data indicated that a greater likelihood of a missed diagnosis was associated with younger age; referrals outside of family practice service; orientation as to person, place, and time; and a history of bipolar affective disorder or psychosis. The ramifications of failure to diagnose existing delirium include increased morbidity and mortality, longer length of hospital stay, and increased healthcare costs.

Japanese Version of the Delirium Rating Scale, Revised-98 (DRS-R98 -J): Reliability and Validity

Background: Delirium is a common neuropsychiatric disorder in medical and surgical inpatients of all ages. It is associated with increased long-term mortality, longer length of hospital stay, poor functional recovery, and increased likelihood of nursing home placement. Objective: The aim of this study was to investigate the reliability and the validity of the Japanese translation of the Delirium Rating Scale, Revised–98 (DRS-R–98). Method: Psychiatric-consultation patients were assessed to compare groups of delirium, dementia, and non-delirium. Results: Mean Total and Severity scores significantly distinguished delirium from the other groups. The scale had high interrater reliability and high internal consistency. Mean Severity scores during delirium differed from the posttreatment scores. Stratum-specific likelihood ratios showed that the DRS-R98 –J is a reliable diagnostic tool. Conclusion: This study indicates that the Japanese version of the DRS-R-98 has high reliability and validity, and is a useful tool for assessing delirium among Japanese medically ill populations. (Psychosomatics 2010; 51:425– 431)

What should non-US behavioral health systems learn from the USA?: US behavior health services trends in the 1980s and 1990s

Abstract  Several countries, such as the USA, inadvertently created a different behavioral health payment system from the rest of medicine through the introduction of diagnostic‐related group exemptions for psychiatric care. This led to isolation in the administration and delivery of care for patients with mental health and substance abuse disorders from other medical services with significant, yet unintended, consequences. To insure an efficient and effective health‐care system, it is necessary to recognize the problems introduced by segregating behavioral health from the rest of medical care. In this review, the authors assess trends in behavioral health services during the last two decades in the USA, a period in which independently managed behavioral health care has dominated administrative practices. During this time, behavioral health has been an easy target for aggressive cost cutting measures. There have been no clinically significant improvements in the number of adults receiving minimally adequate treatment or in the percentage of the population with behavior health problems receiving psychiatric care with the possible exception of depression. While decreased spending for behavioral health services has been well documented during this period, these savings are offset by costs shifted to greater medical service use with a net increase in the total cost of health care. Targeting behavioral health for reduction in health‐care spending through independent management, starting with diagnostic procedure code or diagnostic‐related group exemption may not be the wisest approach in addressing the increasing fiscal burden that medical care is placing on the national economy.

Are the patients with post-transplant psychiatric consultation different from other medical–surgical consultation inpatients?

Abstract  The present study examines the characteristics of post‐transplant patients compared with non‐transplant patients seen by consultation psychiatrists. Medical records of 541 consecutive psychiatric consultation patients at a university teaching hospital in 2001 were reviewed. Of the 541 patients who were evaluated, 67 were post‐transplant patients. Post‐transplant psychiatric consultation is different in some aspects from other psychiatric consultation. Post‐transplant patients suffer complicated medical, psychiatric, and social burdens.

Preferences of help regarding behavioral health problems among the Japanese general population: Letters to the Editor

PROGRESSIVE CEREBRORETINAL MICROANGIOPATHY syndrome is characterized by cerebral calcification and cyst formation (CRMCC), as defined in recent years, and is described in the published reports as Coats plus syndrome, Labrune syndrome and leukoencephalopathy calcification and cysts (LCC) syndrome. Cerebral, ophthalmic, skeletal, intestinal involvement can be seen. CRMCC determined in late adolescence is limited. Autosomal recessive inheritance is reported. In the majority of patients, neurological findings showing progression have been reported, such as spasticity, dystonia, ataxia and loss of cognitive abilities. Imaging findings with laboratory data should support the diagnosis. The case presented here is of a 20-year-old male patient whose indications began in late adolescence and were defined as CRMCC characterized by central nervous system involvement. The patient had a history of febrile convulsions at the age of 2, and until 20 years old had suffered no seizures. He started to have complex partial seizure (CPS) with an aura of loss of speech and extremity numbness followed by extremity spasms accompanied by spasm of the head and neck area, versive rotation movements and manual automatisms after 20 years of age. Familial inheritance was not shown. The neurological and ophthalmological examination was normal. There were no psychiatric, psychological or behavioral problems besides CPS. Memory disturbance due to left temporal lobe dysfunction was determined by the Wechsler Memory Scale (WMS) psychometric tests. Under observation in the video electroencephalography monitorization unit, CPS were seen three times. Seizures lasting up to 1 min were observed, before the seizure, showing a defining aura of loss of speech and numbness on the right side of the body, while during the seizure he had a behavioral arrest, his head was versive turned to the right and there were oral-alimentary and bilateral manual automatisms. Spike, sharp and slow wave activities were observed starting from the left frontal region and emitting to the temporal region during the seizure. For this reason, the seizure from the left frontal region and spread to the left temporal region was concluded. Computed tomography showed multiple calcified foci in the cyst wall, basal ganglia, thalami and cerebral white matter. Magnetic resonance (MR) imaging revealed signal abnormalities in the cerebral white matter, and a right thalamo-caudate cyst and a smaller pontine cyst. There was no restriction of diffusion-weighted MR images. MR spectroscopy demonstrated minimal increase in the choline peak, mild decrease in the N-acetylaspartate peak, and a lactate peak. Serology positive data were not determined. CRMCC cases generally show indications at an early age and the number of cases determined in late adolescence and older is relatively limited. Cases may present with different clinical tables related to the system involvement. To the best of our knowledge, cases of CRMCC-related complex partial seizures have not been reported. In the radiological imaging data of CRMCC syndrome as leukoencephalopathy (demyelinization and white matter edema), calcification and cyst formation were found. It is a syndrome which may accompany retinal microangiopathy. A differential diagnosis of CRMCC should be considered for cases presenting with CPS and radiological imaging findings. The patient gave the authors written informed consent to publish this report. We would like to thank Patricia E. Miller, University of Rochester Medical Center, NY, USA.