June 14, 2005
Patients fear Florida's new policies on prescribing psychiatric medication
from Sun Sentinel
Peggy Symons tried 34 psychiatric drugs until she found two that worked for her.
She was hospitalized 16 times in 30 years, had frequent bouts of depression, psychotic breakdowns and severe mood changes until a psychiatrist found the right combination of medications.
Now, the 54-year-old woman, who lives near Orlando, says her schizophrenia and bipolar disorder are no longer the "most defining thing in her life." But she remains convinced that her illnesses are why she's never had a romantic relationship, never owned a home or had a good job.
"The voices are talking to you and telling you things that are upsetting," she said. "You literally lose touch with the real world."
Symons' new worry is a decision by the state to change the process for prescribing psychiatric medications. Some mental health professionals warn the decision could endanger the health of mentally ill patients.
To save $292 million in the state's $2.5 billion drug program for the poor and disabled, Gov. Jeb Bush's administration persuaded the Florida Legislature this spring to impose strict limits on patient access to mental health drugs. It includes making brand-name drugs less accessible and requiring the poor and disabled to start off on the cheapest drugs first.
"Tragically, for many, the inability to access particular psychotropic medications will result in serious destabilization, while for others it will mean a descent into psychosis," said Kathleen Hale of Miami, president of the National Mental Health Association.
What's more, for weeks Hale has been unable to get state officials to clarify whether existing Medicaid patients like Symons will be affected or whether the new policies affect only new Medicaid patients. State health officials say they haven't responded to Hale because they haven't determined the Legislature's intent.
"Imagine the anxiety for these people, not knowing if in just a few weeks they may no longer have access to medications that keep them from psychosis and keep them able to work, supporting families and functioning normally," Hale said. "Do you make arrangements for someone to take care of you, or for you to be stabilized? Do you tell your children? Your boss?"
Before the changes take place July 1, the state's current list of about 3,000 available drugs will be whittled down by a panel of pharmacists and the state Agency for Health Care Administration, based on price negotiations with drug makers and the clinical value of the drugs.
"If access to these drugs is restricted, people are going to become psychotic," Symons said. "It's complicated getting the medications just right. With these drugs, they can throw a monkey wrench in the body chemistry and set off firestorms in the brain that take months to figure out."
State health officials and some legislators defend the new policies by saying they will help rein in costs of Medicaid, the state-federal program for serving the poor that consumes a quarter of the state's nearly $65 billion budget.
The changes will "control spending and utilization," said Stephanie Walker, a spokeswoman for the state Agency for Health Care Administration. She noted that Florida spends more than $500 million a year on mental health drugs like Zyprexa and Seroquel that are given to those with bipolar disorder and schizophrenia.
Patient advocates say reduced government spending on the pharmacy program will merely force more of the mentally ill into emergency rooms and emotional crisis units, if not jails and prisons.
For the first time too, psychotropic drugs will be put under the same restrictions as other medications covered by Medicaid. Only drugs used to treat HIV/AIDS will remain exempt from restrictions that limit patients to four brand-name prescriptions per month, plus four generics.
More than the brand-name limit, what's troubling some mental health patients is the requirement that psychiatric patients will have to try the cheapest drug first.
Doctors could not prescribe a drug that is off the state's drug list unless they first prescribe an approved drug that did not work satisfactorily. Should the cheapest medication fail, the patient could try the second cheapest drug and so on until finding a more expensive drug that works.
It's what the state calls a "step therapy" process and what critics call a "fail first" strategy. In either case, mentally ill patients and their advocates are frightened because, they say, even a short stint on an improper medication can wreak havoc for the mentally ill and those around them.
"I'm petrified," said Miami-Dade County Judge Steve Leifman, a mental-health advocate. "It's just a whole lot cheaper to get people on the right medication and keep the trust with the patient and keep them out of the criminal justice system," Leifman said, citing South Florida studies about the government cost -- as well as the threat to the safety of the public and law enforcement officials -- in dealing with the mentally ill in crisis.
Dr. Samuel Roura, a Miami psychiatrist, said the state's new policies suggest that officials don't understand that "people are different and that the medication needs to be tailored to the specific individual."
He and other medical experts insist that, unlike medicines used to treat other organs and health conditions like heart disease or stomach troubles, drugs for behavioral disorders and emotional illnesses are prone to major side effects and are not one-size-fit-all solutions in a bottle.
"This is legalizing malpractice for the Medicaid population," Roura said. "We'll be making a decision based on cost and not on sound medical judgment. It's putting the Medicaid population at risk."
Mark Hollis can be reached at mhollis@sun-sentinel.com or 850-224-6214.