Sunday, April 20, 2008

Getting Started

I'm now accepting new patients for my outpatient psychopharmacology practice. The service I offer is primarily the prescription of psychoactive medications, though I do have extensive training in various forms of psychotherapy, and I am certainly willing to use those skills. Let me state from the beginning that though I plan to practice psychopharmacology primarily, this is not meant to imply that other treament modalities are not important. Rather, psychopharm is simply the hardest part to find, and on the market level, this is what most people are looking for (ie most already have a non-MD therapist of some kind, but need someone with training in my medical specialty to prescribe meds.)

The developmental disorders population is certainly the most underserved of all, with very few practitioners specializing in this kind of treatment. It is my fondest hope that I can build a practice primarily with patients with fragile X, autism spectrum disorders, and other developmental disorders; I've never specialized as a child psychiatrist, but I've always treated lots of kids in previous incarnations of my outpatient practice. Patients of all ages will be welcome in this practice, and I like to think that my experience in treating kids, adults, and geriatric patients will help me to provide better care across the entire age spectrum (something which is usually ignored, even in the few groups which do treat developmental disorders-DDs.) Traditionally, DDs are the subspecialty of some child psychiatrists, but few of them continue treating their patients into adulthood. In the past, this was usually because the kids ended up in institutions of one kind or another, so a state hospital psychiatrist would take over---with mixed results, as you might imagine.

Unfortunately, to build a practice like this on a part-time basis, it isn't feasible to work through insurance companies. Their policies are always restrictive, and the red tape is all-consuming; furthermore, since I aniticipate serving a clientele from a wide area, it will not be possible to accept all the different insurance plans. There are many other issues with insurance and managed care companies (ie they don't pay reasonable rates, then they don't even pay the bills they're supposed to pay) which led to my closing my previous outpatient practice. Therefore, I've made the decision to start out with a simple policy: this is old-school private practice---no insurance, cash only. Needless to say this isn't for everyone, but I will say that psychiatry is pretty cheap by today's medical standards, and the pychiatrist is the cheapest part of psychiatric treatment. Getting state-of-the-art psychopharm treatment costs a lot less than getting your car fixed or your house painted, and we don't think of using insurance for those things. And if you compare the hourly rates and total costs of psychiatric treatment with even the simplest legal services, we're a much better deal. But doctors don't go into medicine for the money (really!) so we always feel guilty about actually charging actual people actual money for our services. Well, I've gotten past that guilt, and it's the only way I can do this kind of practice. So, my apologies in advance, but no insurance, no discounts, cash only (actually, PayPal only, but more on that later.)

Thursday, April 17, 2008

A New Kind of Practice

For the last 15 years, my wife an I have been working hard to build a non-profit organization, FRAXA Research Foundation, with the goal of helping our son and all the other kids with fragile X. FRAXA has been a runaway success in all ways, and the research we've funded has resulted in a number of major improvements in treatment for fragile X. I'm quite certain that these treatments will each help significant segments of the autism population as well.

But, here's the frustrating part: even though we've identified a number of available drugs which can treat the core deficits and correct the synaptic defects in fragile X, and even though these drugs have now been tested in the fragile X animal models, many physicians are reluctant to prescribe them. They want to see results from human fragile X clinical trials---appropriate enough, and we're doing these, but the results will take many years to make it into journals. In the meantime, they're using other drugs which are at least as toxic, and may be aggravating the basic problems our kids are facing.

Take the case of lithium: it treats nearly all the facets of fragile X that we can identify in animal models. It's a widely prescribed medication, officially approved by the FDA for the treatment of Bipolar Disorder, and it has a long history of safe use in children. Yet few psychiatrists and no pediatricians will use lithium, and fragile X patients have a very difficult time getting a prescription for it, even with recent reports of success in initial trials.

An even more compelling case is the recent finding of dramatic therapeutic effects from minocycline, a synthetic tetracycline antibiotic. Minocycline appears to be a superb treatment for fragile X, based on preclinical efficacy in animal models. Our initial experience in humans (including my son) is even more promising. Best of all, it's an incredibly benign drug which has been shown safe in millions of patients over dozens of years (and it's cheap, too!) Yet, when fragile X parents go to their doctors armed with this info, their MDs respond that this is a dangerous drug that is too risky for them to prescribe. Huh??? There's a 1 in 10,000 chance of getting (easily reversible) lupus-like side effects or benign intracranial hypertension. 1 in 10,000! But this child has a 1 in 1 chance of having fragile X, and we know that minocycline has beneficial effects (more on that later, but it's unpublished, and I don't want to steal the researcher's thunder.) So, the clinical trials are beginning, but once again, it will be years before all doubts (reasonable and otherwise) can be addressed.

So the question is, how can we get these treatments out there as quickly as possible, within the bounds of good medical care? Inevitably, the answer involves my assuming a more direct role---I have to get back to treating more people myself. That's why I'm getting back into an outpatient practice, to bring some of these research discoveries into the clinic.

Monday, April 14, 2008

I'm Baaaaack!!!!!!

Well, after a very long hiatus (nearly 10 years) I'm heading back to an outpatient practice. In the coming weeks, I'll be describing the scope of this practice and how I hope to run it, along with some musings about the work I've been doing all this time. It's important, because I think it will (or should) shape the way I do things. Details to follow....