An informed consumer is critical to ensure quality care. The mental health professional needs feedback from the client to ensure care is effective. That is as much true for counselors as it is for psychiatrists.

Insurance companies and now Medical Assistance have been increasingly using medication "formularies" to control the cost of their medication budget. Formularies limit the choice of medication for which the insurance company will pay. Often that is because there are a choice between brand name and generic medications or a choice among a number of equivalent brand names. Formularies also limit access to newly developed medications that are considered "experimental." While there may be some notable exceptions, formularies exist primarily to save money. Insurance companies and generic medication manufacturers insist that generic are as high quality as name brands.

The Federal Drug Administration (FDA) sets standards that say generics must be equivalent in quality and potency. However, as with all things, you get what you pay for. Generic manufacturers have to cut corners to be able to offer a cheaper product. Generics may work just fine for most people and most medications, however, there will be exceptions.

Psychotropic medications are no exception. WebMD's Anxiety and Stress Management Blog has an introduction to the topic.

Patients have been telling me for years that there's a problem with their medications when they are switched to generics. I've heard this when I worked in psychiatric hospitals and in private practice and, sometimes, on the board.

[...]The journal Clinical Therapy in both 2003 and 2004 noted that there is a difference between brand and generic medications. The journal Hospital Practice also looked at the differences between generics and brand benzodiazepines. The differences can, according to psychiatrists I've heard from, be as much as 20-30% in the bioavailability of the medication.

Simply put. this translates into the percent of a medication that can be absorbed and utilized. Some psychiatrists have noted that they've had to increase the dose of a generic as much as 50% to get the same effect they would get with the brand name.

As always, medication decisions should be a joint decision with your physician. The more the client understands her needs and her medications, the better the discussion and decision will be.

"Conscientious Objection" by professionals seems to me to be a practice whose ethics is tied to the setting in which one practices and the nature of the limitation one wishes to set. Julian Savulescu, writing about "Conscientious Objection" by physicians in The New British Medical Journal seems to have a much narrower and blanket view.

blog.bioethics.net

A doctors’ conscience has little place in the delivery of modern medical care, writes Julian Savulescu at the University of Oxford. If people are not prepared to offer legally permitted, efficient, and beneficial care to a patient because it conflicts with their values, they should not be doctors.

Imagine an intensive care doctor refusing to treat people over the age of 70 because he believes such patients have had a fair innings. Or imagine an epidemic of bird flu or other infectious disease that a specialist decided she valued her own life more than her duty to treat her patients. Such a set of values would be incompatible with being a doctor.

The argument in favour of allowing conscientious objection is that to fail to do so harms the doctor and constrains liberty. This is true, says the author, but when conscientious objection compromises the quality, efficiency, or equitable delivery of a service, it should not be tolerated.

He believes that doctors who compromise the delivery of medical services to patients on conscience grounds must be punished through removal of licence to practise and other legal mechanisms.

Values are important parts of our lives. But values and conscience have different roles in public and private life, he writes. They should influence discussion on what kind of health system to deliver. But they should not influence the care an individual doctor offers to his or her patients.

The door to “value-driven medicine” is a door to a Pandora’s box of idiosyncratic, bigoted, discriminatory medicine. Public servants must act in the public interest, not their own, he concludes.

Every health care worker at some point in their training becomes aware that their right to deny treatment is limited most often by the setting in which they choose to work. Each person knows when they enter a particular position that their right to deny treatment is restricted.

The right to deny treatment based on political or moral values is often contrary to the mission of the setting in which the professional practices. A health care worker working for an agency would tacitly accept the mission of the agency for which they work. Health care agencies often serve the community with limitations only based on payer. Many public settings may allow an acceptable work around, such as referring to a colleague. If such accommodation is not available, the concerned health care worker should understand that when he/she accepts the job.

I'm not that familiar with the British medical practice design, but I'm hard pressed to believe that a professional in private practice has the same limitations as someone working in an agency that serves the whole community.

If the desired limitation is based on a particular procedure, then it seems to me that private practice enables a professional to limit their practice. As long as the private practitioner wishing to limit his/her practice operates by fully informing the client of all treatment alternatives, regardless of any qualms and without prejudice or proselytizing his/her beliefs, and offers a good faith referral to a professional which is willing to perform the service, no harm is done.

However, a limitation based on a particular client characteristic is much more complicated. It seems likely if a professional chose to limit their practice to caucasians based on a bias towards other races, the practitioner would likely be subject to civil litigation and could correctly be censured by their licensing agency for discrimination.

However, many professionals limit their practice to particular illnesses, problems, genders and age groups. One could justifiably assert a limitation in his/her cultural competency. They would be obligated to inform a client of their lack of expertise and competence and could appropriately refer them elsewhere.

This a very important and complex topic and one that will surely receive more attention in the future. My opinion seems likely to evolve.

MedlinePlus

Nearly two thirds of U.S. college students are affected by sexual harassment -- ranging from offensive jokes and gestures to touching and grabbing, according to a study released on Tuesday. Men are more likely to harass than women, but women and men are equally likely to be harassed on U.S. campuses, according to a report by the American Association of University Women.

Researchers found that 62 percent of college students experienced sexual harassment, and 32 percent of college students said they were victims of physical harassment. "The primary form of harassment that we're seeing is actually non-contact: it tends to be remarks, gestures and jokes," Elena Silva, the report's co-author, said in a telephone interview. "But the fact that one third of college students are experiencing some form of physical harassment is certainly a concern."

In a representative survey of 2036 undergraduates at U.S. colleges and universities, 41 percent said they had sexually harassed someone. "In most cases, these students say that they thought it was funny, the other person liked it, or it is 'just a part of school life,'" the report found.

Common types of physical harassment include being touched, grabbed or pinched in a sexual way, or intentionally brushing up against someone in a sexual way, the study found.

Sexual harassment like most forms of harassment is an act seen differently by different people. Some people don't see their actions as harassing, but as teasing. However, anyone who has experienced incessant teasing understands how something initially perceived as a tease can quickly move to annoying, and then to harassing based on frequency, context and content. The study above found that most harassment is intended by the harasser as a tease.

Sometimes sexual harassment is deliberately malicious. Too often behavior meant as an innocent tease is seen as inappropriate and even intimidating.

The best advice I can offer to people who think they are teasing, is that touch of any kind is not ok without permission. Even verbal teasing is simply not appropriate unless you know the person very well and are sure what the response will be. When in doubt, don't do it!

For those that feel harassed, it is important to "nip it in the bud". An immediate comment directly to the harasser about how the behavior is undesired should in most cases end the behavior. If the harasser doesn't stop, or is in a position of authority over you, and you do not feel safe approaching the person directly, you probably have at least two choices. Send the person a written memo describing in detail the behavior, how it is perceived, and requesting that it stop. Or you can go directly to the person's supervisor. In all cases, keep a detailed written record of the behavior and your attempts to end it, and the response of those you approach.

Should the problem continue, you will have a written record with descriptions, times and dates and the basis to take the complaint to a formal investigation. Bring your a copy of your written record up the chain of command until you have exhausted all options internal to the organization. If you can't find satisfaction internally, you may have to bring the complaint to an attorney or a human rights ombudsman in your local community or state.

The only way to prevent sexual harassment is with school and work place education. But even with education, the only sure way for the victim to protect her/himself is to have the courage to stop it.

Clients often see diagnosis as some sort of magical rite of passage into the mysterious world of mental health treatment. Actually, diagnosis is largely overrated. Many clinicians wouldn't use it routinely in any formal way if insurance companies didn't require a diagnosis for payment.

Diagnosis is helpful for communicating about treatment between professionals. But as a guide that carries any stable meaning over time, it's value is limited. People are much more complex and not amenable to fitting into catagories. And the diagnostic catagories are far from accurate and reliable across different episodes of illness or even between professionals seeing the same client at the same time.

The structure of the DSM IV is based on how a group symptoms suggest a particular diagnosis from research and clinical experience of the participating professionals. Some clinicians have thought of the DSM IV as a recipe for diagnosis that removes much meaning from the practice. Diagnosis reduced to it's most simple terms becomes simplistic, lacking any meaningful information about the development and treatment of the disorder.

But now there is a new Diagnostic Manual available. In the spirit of Sigmund Freud, the American Psychoanalytic Association has written it's own version. This manual is based less on phenomenology and more on theory based on clinical experience dating from current times back to the time of Freud. Will it prove better? Only time will tell.

New York Times

Now, in an effort to provide more of this context, a coalition of organizations representing psychoanalytically oriented therapists has produced a diagnostic manual of its own. Unlike most psychiatrists, psychoanalysts focus their efforts on understanding the meaning and the psychological roots of mental suffering, rather than on diagnosing mental disorders and treating them with drugs or less intensive methods of talk therapy.

The new guidebook, unveiled Saturday at the annual meeting of the American Psychoanalytic Association, is modeled on the standard diagnostic manual in its format and its title, the Psychodynamic Diagnostic Manual. But it emphasizes the importance of individual personality patterns, like masochistic, dependent or depressive types, which are found in many people but which qualify as full-blown disorders only at the extremes.