FBT Insights from the Neonatal Kitten Nursery

Parents feed children in FBT Kitten CollageI recently began volunteering at the Best Friends Neonatal Kitten Nursery. Best Friends Los Angeles opened its neonatal kitten nursery in February 2013.  The nursery is staffed with a dedicated coordinator and supported by volunteers who sign up for two hour feeding shifts 24 hours a day to help the kittens grow and thrive.

If you were an abandoned kitten in the Los Angeles area, or even a kitten with a mother, you’d be lucky to make your way to the Best Friends Neonatal Kitten Nursery.

The most vulnerable animals in the Los Angeles shelters are newborn kittens, often abandoned at birth, or turned into shelters from accidental litters. Because the kittens cannot feed themselves, they will die without someone to bottle feed them.

In the mommy and me section of the nursery, mothers nurse their kittens. In the other sections, kittens are bottle-fed, tube-fed, or syringe-fed until they are able to eat gruel on their own. Kittens are weighed before and after each feeding. If their weights are not steadily going up, the interventions increase. They are very fragile at this age.

The other night, the nursery coordinator, Nicole, was tube-feeding some kittens who were ill. As she explained, they were feeling too sick to eat on their own. Although acknowledging that her tube feeding was making them angry, Nicole was resolute. No kitten would starve to death on her watch. Of course, I connected this back to my families working to re-feed their children with anorexia.

In the neonatal nursery, we don’t spend time thinking about why the kitten is not nursing or eating in the expected fashion. If they are sick, they are treated for that, but in the meantime, every kitten is fed around the clock and those who don’t have mothers are bottle fed, those who won’t nurse from their mothers (often when they are too congested) are tube-fed, and those who won’t eat gruel independently are syringe-fed.

How does this relate to parents doing Family Based Treatment (FBT) for Eating Disorders with children who have Anorexia?

Of course, parents do not literally force food down human children’s throats, but they do set up contingencies to require eating even if the child doesn’t feel well and even if they rail and resist and are angry about it.

This is the heart of FBT Phase 1. When children are not able to eat on their own (due to an eating disorder) parents are instructed to nourish their starving child back to health. Parents need to step in and help their children make steady weight gains until they are able to eat on their own. Parents need to be resolute and not worry about their children being angry at them. They also should not spend time exploring why their child is not eating.

For further information on parental direction over eating in FBT, check out this prior blog post.

 

Look before you leap: Binge Eating Disorder, Vyvanse, and evidence-based psychotherapies

Binge Eating Disorder, Vyvanse, and evidence-based psychotherapiesGuest post by Elisha M. Carcieri, Ph.D. 

Binge eating disorder (BED) has been making headlines with the recent announcement that the FDA has approved lisdexamfetamine dimesylate (Vyvanse) for the treatment of BED.

So, what is BED, how is it treated, and what does this new treatment option mean for sufferers?

What is Binge Eating Disorder

BED is a condition in which a person engages in recurrent episodes of binge eating at least once a week for three months1. Binge eating episodes typically involve eating rapidly until uncomfortably full, and eating when one is not necessarily hungry. Some individuals with BED report feeling unable to stop the episode, and describe themselves as being out of control during a binge. Binge eaters often binge alone and make efforts to hide their behavior from friends, partners, or family members. Episodes of binge eating often end in feelings of guilt, shame, and depressed mood. Unlike other eating disorders, such as bulimia nervosa, people with BED do not vomit or use other methods of compensation (such as excessive exercise or fasting) to shed calories or lose weight after a binge. It should be clear that this is a very different experience than, say, overeating on Thanksgiving, having a second piece of birthday cake, or eating foods that are outside of your normal pattern while on vacation.

Until 2013, BED was not a diagnosable eating disorder. It was instead grouped in with other unspecified eating disorders that didn’t quite meet criteria to be formally diagnosed. After much research, the most recent iteration of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), has included BED as a specific eating disorder distinct from other diagnoses.

Despite only recently being formally acknowledged, BED is the most commonly occurring eating disorder. Prevalence estimates vary, ranging from 1.6-3.5% of women, 0.8-2% of men, and 1.6% of adolescents.1, 2, 3 BED occurs as commonly among women from racial or ethnic minority groups as for white women, 1 and is often seen in people with severe obesity.1, 4 Up to 30% of people seeking bariatric surgery or other interventions for weight loss are suffering from BED5. While it is more common for women to meet all of the criteria for BED, men tend to engage in binge eating as frequently as women2. Like all eating disorders, the causes of BED are complex. There is evidence for genetic, biological, and environmental risk factors. BED is associated with significant chronic health problems. It is also common for individuals with BED to struggle with other mental health disorders at the same time, including depression, anxiety, and substance use disorders.

The good news is that there are established treatments that work for BED. Unfortunately, effective psychological interventions for eating disorders don’t get as much press as pharmaceuticals. Nevertheless, those suffering from BED should be aware of what is available.

Treatment for Binge Eating Disorder

Evidence-based psychological treatments are first-line considerations for the treatment of BED. A psychologist or other mental health professional qualified to treat eating disorders usually conducts psychological treatment for BED on an outpatient basis. Cognitive behavioral therapy (CBT) is the most well studied and established treatment for BED with demonstrated effectiveness.6 The treatment involves reducing episodes of binge eating using tools such as establishing regular eating patterns and self-monitoring of food intake and patterns of eating. CBT also addresses concerns about shape and weight, and examines and challenges patterns of thinking that may be keeping a person stuck in a pattern of binge eating. CBT for BED involves discussion and planning of how to maintain progress, and how to recognize and respond to relapse. Studies have demonstrated improvements lasting up to 12 months post-treatment with CBT.7 Interpersonal therapy (IPT) has also been proven effective for BED with strong research support.8 IPT involves more of a focus on interpersonal (relationship) difficulties with an understanding of how these problems may have precipitated BED, or how they might be keeping the BED going. Finally, there is evidence that dialectical behavior therapy (DBT), which focuses on mindfulness, emotion regulation, and distress tolerance, is effective at treating BED.9

Pharmacological Treatments for Binge Eating Disorder

In addition to psychological treatments, some antidepressants and anticonvulsants have proven helpful at reducing the frequency of binge eating in patients with BED.6 The newest and only medication specifically approved by the FDA for BED is Vyvanse, a central nervous system stimulant that has been approved to treat ADHD in children and adults since 2007. The approval for BED came after clinical trials demonstrated that the average number of binge eating days per week among sufferers were decreased in those who took Vyvanse, compared to those who took a placebo.10 Sounds promising…but there are other considerations to keep in mind…side effects, long-term use, and the question of whether a medication can address the complex nature of a serious eating disorder such as BED.

The potential side effects of Vyvanse include decreased appetite, dry mouth, increased heart rate or blood pressure, difficulty sleeping, anxiety, gastrointestinal problems, feeling jittery, and even sudden death among people with heart problems. The drug is also particularly risky for individuals with a history of seizures or mania. Vyvanse may cause psychotic or manic symptoms in people with no history of mental illness, and has a high potential for abuse, dependence, tolerance, and overdose.

Vyvanse appears to decrease symptoms over a short period of time (about three months) while taking the medication. However, it is unlikely that the medication will result in long-term changes in complex binge eating behavior once the drug is stopped, meaning that one might expect to take Vyvanse for the rest of their lives in order to keep BED at bay. This is problematic considering the chronic nature of BED, 2 and the fact that the negative emotion, distress, shame, and weight or shape concerns that are often related to BED would almost certainly remain unaddressed.

While there are no identified side effects to engaging in psychological treatment of BED, these treatments do take time (often around 20 weeks), and not every person will respond to an intervention the same way. It may take some trial and error to find the right therapist or treatment. However, psychological treatments are more equipped than medication alone to address the binge eating behavior itself, and the different ways binge eating relates to other areas of a person’s life and functioning. Rather than simply masking and reducing symptoms in the short term with a medication, completing a course of evidence-based therapy can provide the insight and tools needed for managing the patterns of disordered eating that are characteristic of BED for life. Many people with BED may benefit from trying a psychological approach before initiating treatment with a serious medication like Vyvanse.

Implications for Patients

All of these factors should be carefully considered when making a decision about treatment for BED. With all eating disorders including BED, it is important to get help sooner rather than later. For many people, turning to their primary care doctor is the first step. Patients should keep in mind that these conversations can be sensitive and difficult, and many providers may not be familiar with BED. Other providers may be familiar with the recent approval of a new drug, and will be eager to explore prescription medication options for treatment.

If you aren’t getting anywhere with your doctor, it is always appropriate to ask for a referral to a medical provider who is more familiar with eating disorders. Your doctor may also be able to provide you with a referral to a mental health provider, such as a psychologist, who can provide one of the therapies discussed above, and to a nutritionist or dietician who specializes in eating disorders for even more comprehensive support. Remember that it is important to seek help from professionals qualified to treat eating disorders, and treatment decisions should be tailored to the unique needs of each person.

If you do see a psychiatrist regarding any medication, we have some recommendations.

References

1. American Psychiatric Association. (2013). The Diagnostic and Statistical Manual of Mental Disorders: DSM 5. bookpointUS.

2. Hudson, J. I., Hiripi, E., Pope Jr, H. G., & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological psychiatry, 61(3), 348-358.

3. Swanson, S. A., Crow, S. J., Le Grange, D., Swendsen, J., & Merikangas, K. R. (2011). Prevalence and correlates of eating disorders in adolescents: Results from the national comorbidity survey replication adolescent supplement. Archives of General Psychiatry, 68(7), 714-723.

4. Marcus, M. D., & Levine, M. D. (2005). Obese patients with binge-eating disorder. In The management of eating disorders and obesity (pp. 143-160). Humana Press.

5. Kalarchian, M. A., Marcus, M. D., Levine, M. D., Courcoulas, A. P., Pilkonis, P. A., Ringham, R. M., … & Rofey, D. L. (2007). Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status. The American journal of psychiatry, 164(2), 328-334.

6. Brownley, K. A., Berkman, N. D., Sedway, J. A., Lohr, K. N., & Bulik, C. M. (2007). Binge eating disorder treatment: a systematic review of randomized controlled trials. International Journal of Eating Disorders, 40(4), 337-348.

7. Wilson, G. T., Grilo, C. M., & Vitousek, K. M. (2007). Psychological treatment of eating disorders. American Psychologist, 62(3), 199.

8. Wilfley, D. E., Welch, R. R., Stein, R. I., Spurrell, E. B., Cohen, L. R., Saelens, B. E., … & Matt, G. E. (2002). A randomized comparison of group cognitive-behavioral therapy and group interpersonal psychotherapy for the treatment of overweight individuals with binge-eating disorder. Archives of general psychiatry, 59(8), 713-721.

9. Telch, C. F., Agras, W. S., & Linehan, M. M. (2001). Dialectical behavior therapy for binge eating disorder. Journal of consulting and clinical psychology, 69(6), 1061.

10. McElroy S. L., Hudson, J. I., Mitchell, J. E., et al. (2014) Efficacy and Safety of Lisdexamfetamine for Treatment of Adults With Moderate to Severe Binge-Eating Disorder: A Randomized Clinical Trial. JAMA Psychiatry.

Elisha Carcieri, Ph.D., is a licensed clinical psychologist (PSY #26716) practicing in the Los Angeles area. Dr. Carcieri earned her bachelors degree in psychology from The University of New Mexico and completed her doctoral degree in clinical psychology at Saint Louis University. During her graduate training, she conducted research focused on eating disorders and obesity, and was trained in using cognitive behavioral therapy (CBT) for eating disorders and other mental health disorders such as anxiety and depression. Dr. Carcieri completed her postdoctoral fellowship at the Long Beach VA Medical Center, where she worked with Veterans coping with mental illness, disability, significant acute or chronic health concerns, and chronic pain. In addition to cognitive behavioral strategies, she also incorporates alternative evidence-based approaches such as mindfulness, and acceptance and commitment-based strategies, depending on the needs of each client. Dr. Carcieri has experience working with culturally diverse clients representing various aspects of diversity including race/ethnicity, gender, age, disability, and size, and welcomes new clients from all backgrounds. She is a member of the American Psychological Association (APA), the Academy for Eating Disorders (AED), and the Los Angeles County Psychological Association (LACPA). 

Who Killed the 50 minute session?

What Consumers Should Know about Changes to Psychotherapy Sessions in 2013

By Lauren Muhlheim, Psy.D., CEDS and Kantor & Kantor, LLP

Unbeknownst to most mental health consumers, a change went into effect in January, 2013 that may have far-reaching ramifications for those receiving outpatient psychotherapy.  For the first time in 15 years, changes were made to the coding system used to describe and bill for mental health treatment.   This change has resulted in chaos for many mental health professionals who bill their patients’ insurance.  Nationwide, many mental health providers have reported problems with filing and receiving timely reimbursement for claims filed under the new coding system.

Why were the Current Procedural Terminology (CPT) codes changed?  The Centers for Medicare and Medicaid Services (CMS) establishes the Current Procedural Terminology (CPT) codes that providers use to communicate with insurance companies.  The CPT codes are periodically reviewed in partnership with the American Medical Association (AMA).  For the last several years, the AMA and the American Psychiatric Association (APA) advocated for changes in the codes that would treat (and reimburse psychiatrists) like other physicians.  Psychiatrists have traditionally been on the low rung of physician pay scales.  The changes allow (and now require) psychiatrists to bill separately for the different services they frequently provide in the course of a single session (medical examination, psychotherapy, and medication management).  The hope was that the new codes, in providing more flexibility in session length, would highlight the complexity and diversity of what psychiatrists do.  There are additional “add on” codes for “complexity” as well as for crisis management.  Since all mental health providers use the same psychotherapy codes, non-psychiatrists have had to adopt these as well.

For the majority of recent psychological treatment history, the standard 50- minute therapy session was billed to insurance under the CPT code “90806”, and was officially described as “individual therapy 45-50 min.” In practice, most therapists have scheduled patients on the hour and allocated one hour per patient, spending approximately 50 minutes face to face.  This often stretches to 55 minutes by the time one handles payments and schedules the next appointment and allows a few minutes between clients for notes, bathroom breaks, and checking messages.  In 2013, the 90806 code was eliminated and replaced with several alternatives:

  • 90832 – psychotherapy 30 minutes
  • 90834 – psychotherapy 45 minutes
  • 90837 – psychotherapy 60 minutes

Practitioners were informed about the change in October 2012, but given little specific information on how to use them.  The American Psychiatric Association provided the following interpretation:

Note: Since the new psychotherapy codes are not for a range of time, like the old ones, but for a specific time, the CPT “time rule” applies. If the time is more than half the time of the code (i.e., for 90832 this would be 16 minutes) then that code can be used. For up to 37 minutes you would use the 30 minute code; for 38 to 52 minutes, you would use the 45-minute code, 90834; and for 53 minutes and beyond, you would use 90837, the 60-minute code.

By “time,” the APA means face-to-face time with the client.

So what’s the hitch?  The 50-minute session suddenly no longer exists, and that creates a problem. Many practitioners assume the 45-minute session is the intended replacement for the 50-minute session.  However, they fear that reducing time spent with patients will both reduce treatment efficacy, as well as be used as justification by insurance companies to reduce reimbursement rates.  Remember, reimbursement rates haven’t been raised in 18 years and are typically only half of what a patient would pay if they didn’t have insurance.  The other option, the 60-minute session, makes it harder for therapists to complete paperwork and take bathroom breaks unless they space clients further apart, complicating schedules for everyone involved.  And it’s not even clear whether insurers will choose to cover the 60-minute session.   It appears that some insurers are not.

For psychiatrists, the new codes are extremely complicated. The 2013 Medicare fee schedule reveals that reimbursement for psychiatric evaluations with medical services – those done by psychiatrists – will be lower than reimbursements for psychiatric evaluations done by social workers and psychologists.  “This makes no sense, and seems to run counter to the premise that creating a comprehensive system of coding services would create an appreciation for the complexity of the medical aspects of treating mental disorders, address parity, and decrease the stigma to seeing a psychiatrist.”[1]

The CPT changes have thus far resulted in confusion and delays in processing mental health claims because insurance companies were not prepared, equipped, or organized for this change.   Insurance companies had not yet set rates for the new codes, nor had they decided which codes they would accept.  As a result, claim processing since the first of the year has been slow, impacting patients, therapists, and insurance companies.   Helen Stojic, a spokeswoman for Blue Cross Blue Shield of Michigan told NBC News, “The amount of changes and the work involved was much bigger than … the folks involved anticipated.”[2]

Around the country, mental health providers have reported problems with insurance reimbursement.  Some are reporting financial difficulty due to the delay in cash flow.  The biggest worry, however, is that this coding chaos will affect care for millions of vulnerable patients.

What does this mean for providers? In simple terms, less pay, delayed payment, and financial hardship.  “We are ethically bound not to leave patients hanging,” Steven Perlow, president of the Georgia Psychological Association and a psychologist in private practice said. “I will personally see people for a sliding scale … there have been situations where I’ve seen people for free.”[3] Additionally, providers may experience disincentives to stay on insurance panels.  Lastly, these factors may affect providers’ ability to deliver quality care.

What does this mean for patients? To start with, session lengths could be reduced by 10%, meaning less treatment.  Furthermore, patients may have increased difficulty finding practitioners who are willing to accept insurance. Therapists may very well be waiting to see what is happening with reimbursement rates before accepting more insurance patients, or may leave panels altogether.

These outright denials of payment and system wide delays have caused chaos among providers and their patients, and could last for months.  This disorder and confusion has the potential to jeopardize access to care for millions of mentally ill Americans, who depend upon the stability of treatment from their mental health providers.

Action Plan

If you feel that the 2013 psychotherapy CPT codes have negatively affected how you are able to deliver or receive patient care, let your voice be heard:

http://www.realpsychpractice.com/2013-cpt-codes/

Lauren Muhlheim, Psy.D., CEDS

Lauren Muhlheim, Psy.D., CEDS is a psychologist and certified eating disorder specialist practicing in Los Angeles.  She specializes in providing evidence-based psychotherapy for adults and adolescents.  www.laurenmuhlheim.com

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Kantor & Kantor is one of the most experienced and highly respected law firms dealing with the prosecution of claims against insurance companies. If your insurance company has unfairly denied payment for benefits, we can help. Call (800) 446-7529 or log on to www.kantorlaw.net.


[2] JoNel Aleccia, NBC News, Glitch in medical code threatens mental health care, therapists warn, http://vitals.nbcnews.com/_news/2013/02/07/16842490-therapists-change-in-medical-coding-threatens-mental-health-care#.URPN_3hBLqc.twitter (February 7, 2013).

3 JoNel Aleccia, NBC News, Glitch in medical code threatens mental health care, therapists warn, http://vitals.nbcnews.com/_news/2013/02/07/16842490-therapists-change-in-medical-coding-threatens-mental-health-care#.URPN_3hBLqc.twitter (February 7, 2013).