Reviews

Manic episodes, by definition, are associated with significant social or occupational impairment.¹ Some manic patients are violent or engage in reckless behaviors that can harm themselves or others, such as speeding, disrupting traffic, or playing with fire. When these patients present to a psychiatrist’s outpatient practice, involuntary hospitalization might be justified.

However, some manic patients, in spite of their elevated, expansive, or irritable mood state, never behave dangerously and might not meet legal criteria for involuntary hospitalization, although these criteria differ from state to state. These patients might see a psychiatrist because manic symptoms such as irritability, talkativeness, and impulsivity are bother­some to their family members but pose no serious danger (Box). In this situation, the psychiatrist can strongly encourage the patient to seek voluntary hospitalization or attend a partial hospitalization program. If the patient declines, the psychiatrist is left with 2 choices: initiate treatment in the outpatient setting or refuse to treat the patient and refer to another provider.

Treating “non-dangerous” mania in the outpatient setting is fraught with challenges:
   • the possibility that the patient’s condition will progress to dangerousness
   • poor adherence to treatment because of the patient’s limited insight
   • the large amount of time required from the psychiatrist and care team to adequately manage the manic episode (eg, time spent with fam­ily members, frequent patient visits, and managing communications from the patient).

There are no guidelines to assist the office-based practitioner in treating mania in the outpatient setting. When considering dosing and optimal medication combina­tions for treating mania, clinical trials may be of limited value because most of these studies only included hospitalized manic patients.

Because of this dearth of knowledge, we provide recommendations based on our review of the literature and from our expe­rience working with manic patients who refuse voluntary hospitalization and could not be hospitalized against their will. These recommendations are organized into 3 sec­tions: diagnostic approach, treatment strat­egy, and family involvement.

Diagnostic approach
Making a diagnosis of mania might seem straightforward for clinicians who work in inpatient settings; however, mania might not present with classic florid symptoms among outpatients. Patients might have a chief concern of irritability, dysphoria, anxiety, or “insomnia,” which may lead clinicians to focus initially on non-bipolar conditions.²

During the interview, it is important to assess for any current DSM-5 symptoms of a manic episode, while being careful not to accept a patient’s denial of symptoms. Patients with mania often have poor insight and are unaware of changes from their base­line state when manic.³ Alternatively, manic patients may want you to believe that they are well and could minimize or deny all symptoms. Therefore, it is important to pay attention to mental status examination find­ings, such as hyperverbal speech, elated affect, psychomotor agitation, a tangential thought process, or flight of ideas.

Countertransference feelings of diagnos­tic confusion or frustration after long patient monologues or multiple interruptions by the patient should be incorporated into the diagnostic assessment. Family members or friends often can provide objective obser­vations of behavioral changes necessary to secure the diagnosis.

Treatment strategy
Decision points. When treating manic out­patients, assess the need for hospitalization at each visit. Advantages of the inpatient setting include:
   • the possibility of rapid medication adjustments
   • continuous observation to ensure the patient’s safety
   • keeping the patient temporarily removed from his community to prevent irrevers­ible social and economic harms.

However, a challenge with hospitaliza­tion is third-party payers’ influence on a patient’s length of stay, which may lead to rapid medication changes that may not be clinically ideal.

At each outpatient visit, explore with the patient and family emerging symptoms that could justify involuntary hospitaliza­tion. Document whether you recommended inpatient hospitalization, the patient’s response to the recommendation, that you are aware and have considered the risks associated with outpatient care, and that you have discussed these risks with the patient and family.

For patients well-known to the psychia­trist, a history of dangerous mania may lead him (her) to strongly recommend hos­pitalization, whereas a pre-existing thera­peutic alliance and no current or distant history of dangerous mania may lead the clinician to look for alternatives to inpatient care. Concomitant drug or alcohol use may increase the likelihood of mania becoming dangerous, making outpatient treatment ill-advised and riskier for everyone involved.

In exchange for agreeing to provide out­patient care for mania, it often is helpful to negotiate with the patient and family a threshold level of symptoms or behavior that will result in the patient agreeing to voluntary hospitalization (Table 1). Such an agreement can include stopping outpatient treatment if the patient does not improve significantly after 2 or 3 weeks or develops psychotic symptoms. The negotiation also can include partial hospitalization as an option, so long as the patient’s mania con­tinues to be non-dangerous.

 

Obtaining pretreatment blood work can help a clinician determine whether a medication is safe to prescribe and establish causality if laboratory abnormalities arise after treatment begins. Ideally, the psychia­trist should follow consensus guidelines developed by the International Society for Bipolar Disorders⁴ or the American Psychiatric Association (APA)⁵ and order appropriate laboratory tests before prescrib­ing anti-manic medications. Determine the pregnancy status of female patients of child-bearing age before prescribing a potentially teratogenic medication, especially because mania is associated with increased libido.⁶

Manic patients might be too disorga­nized to follow up with recommendations for laboratory testing, or could wait sev­eral days before completing blood work. Although not ideal, to avoid delaying treat­ment, a clinician might need to prescribe medication at the initial office visit, without pretreatment laboratory results. When the patient is more organized, complete the blood work. Keeping home pregnancy tests in the office can help rule out pregnancy before prescribing medication.

Medication. Meta-analyses have estab­lished the efficacy of mood stabilizers and antipsychotics for treating mania,^7,8 and sev­eral consensus guidelines have incorporated these findings into treatment algorithms.⁹

For a patient already taking medications recommended by the guidelines, assess treatment adherence during the initial inter­view by questioning the patient and family. When the logistics of phlebotomy permit, obtaining the blood level of psychotropics can show the presence of any detectable drug concentration, which demonstrates that the patient has taken the medication recently.

If there is no evidence of nonadherence, an initial step might be to increase the dos­age of the antipsychotic or mood stabilizer that the patient is already taking, ensuring that the dosage is optimized based on FDA indications and clinical trials data. The rec­ommended rate of dosage adjustments dif­fers among medications; however, optimal dosing should be reached quickly because a World Federation of Societies of Biological Psychiatry task force recommends that a mania treatment trial not exceed 2 weeks.¹⁰

Dosage increases can be made at weekly visits or sooner, based on treatment response and tolerability. If there is no ben­efit after optimizing the dosage, the next step would be to add a mood stabilizer to a second-generation antipsychotic (SGA), or vice versa to promote additive or syn­ergistic medication effects.¹¹ Switching one medication for the other should be avoided unless there are tolerability concerns.

For a patient who is not taking any medi­cations, select a treatment that balances rapid stabilization with long-term efficacy and tolerability. Table 2 lists FDA-approved treatments for mania. Lamotrigine provides prophylactic efficacy with few associated risks, but it has no anti-manic effects and would be a poor choice for most actively manic patients. Most studies indicate that antipsychotics work faster than lithium at the 1-week mark; however, this may be a function of the lithium titration schedule followed in the protocols, the severity of mania among enrolled patients, the inclu­sion of typically non-responsive manic patients (eg, mixed) in the analysis, and the antipsychotic’s sedative potential rela­tive to lithium. Although the anti-manic and prophylactic potential of lithium and valproate might make them an ideal first-line option, antipsychotics could stabilize a manic patient faster, especially if agitation is present.^12,13

Breaking mania quickly is important when treating patients in the outpatient set­ting. In these situations, a reasonable choice is to prescribe a SGA, because of their rapid onset of effect, low potential for switch to depression, and utility in treating classic, mixed, or psychotic mania.¹⁰ Oral loading of valproate (20 mg/kg) is another option. An inpatient study that used an oral-loading strategy demonstrated a similar time to response as olanzapine,¹⁴ in contrast to an inpatient¹⁵ and an outpatient study¹⁶ that employed a standard starting dosage for each patient and led to slower improve­ment compared with olanzapine.

SGAs should be dosed moderately and lower than if the patient were hospitalized, to avoid alienating the patient from treat­ment by causing intolerable side effects. In particular, patients and their families should be warned about immediate risks, such as orthostasis or extrapyramidal symptoms. Although treatment guidelines recommend combination therapy as a possible first-line option,⁹ in the outpatient setting, monother­apy with an optimally dosed, rapid-acting agent is preferred to promote medication adherence and avoid potentially danger­ous sedation. Manic patients experience increased distractibility and verbal memory and executive function impairments that can interfere with medication adherence.¹⁷ Therefore, patients are more likely to fol­low a simpler regimen. If SGA or valpro­ate monotherapy does not control mania, begin combination treatment with a mood stabilizer and SGA. If the patient experi­ences remission with SGA monotherapy, the risks and benefits of maintaining the SGA vs switching to a mood stabilizer can be discussed.

 

Provide medication “as needed” for agitation—additional SGA dosing or a benzodiazepine—and explain to fam­ily members when their use is warranted. Benzodiazepines can provide short-term benefits for manic patients: anxiety relief, sedation, and anti-manic efficacy as mono­therapy^18-20 and in combination with other medications.²¹ Studies showing mono­therapy efficacy employed high dosages of benzodiazepines (lorazepam mean dos­age, 14 mg/d; clonazepam mean dosage, 13 mg/d)¹⁹ and high dosages of antipsy­chotics as needed,^18,20 and often were associ­ated with excessive sedation and ataxia.^18,19 This makes benzodiazepine monotherapy a potentially dangerous approach for out­patient treatment of mania. IM lorazepam treated manic agitation less quickly than IM olanzapine, suggesting that SGAs are preferable in the outpatient setting because rapid control of agitation is crucial.²² If pre­scribed, a trusted family member should dispense benzodiazepines to the patient to minimize misuse because of impulsivity, distractibility, desperation to sleep, or plea­sure seeking.

SGAs have the benefit of sedation but occasionally additional sleep medica­tions are required. Benzodiazepine recep­tor agonists (BzRAs), such as zolpidem, eszopiclone, and zaleplon, should be used with caution. Although these medicines are effective in treating insomnia in indi­viduals with primary insomnia²³ and major depression,²⁴ they have not been studied in manic patients. The decreased need for sleep in mania is phenomenologically²⁵ and perhaps biologically different than insomnia in major depression.²⁶ Therefore, mania-associated sleep disturbance might not respond to BZRAs. BzRAs also might induce somnambulism and other parasom­nias,²⁷ especially when used in combination with psychotropics, such as valproate²⁸; it is unclear if the manic state itself increases this risk further. Sedating antihistamines with anticholinergic blockade, such as diphenhydramine and low dosages (<100 mg/d) of quetiapine, are best used only in combination with anti-manic medi­cations because of putative link between anticholinergic blockade and manic induc­tion.²⁹ Less studied but safer options include novel anticonvulsants (gabapen­tin, pregabalin), melatonin, and melatonin receptor agonists. Sedating antidepressants, such as mirtazapine and trazodone, should be avoided.²⁵

Important adjunctive treatment steps include discontinuing all pro-manic agents, including antidepressants, stimulants, and steroids, and discouraging use of caffeine, energy drinks, illicit drugs, and alcohol. The patient should return for office visits at least weekly, and possibly more frequently, depending on severity. Telephone check-in calls between scheduled visits may be nec­essary until the mania is broken.

Psychotherapy. Other than supportive therapy and psychoeducation, other forms of psychotherapy during mania are not indicated. Psychotherapy trials in bipolar disorder do not inform anti-manic efficacy because few have enrolled acutely manic patients and most report long-term benefits rather than short-term efficacy for the index manic episode.³⁰ Educate patients about the importance of maintaining regular social rhythms and taking medication as pre­scribed. Manic patients might not be aware that they are acting differently during manic episodes, therefore efforts to improve the patient’s insight are unlikely to succeed. More time should be spent emphasizing the importance of adherence to treatment and taking anti-manic medications as pre­scribed. This discussion can be enhanced by focusing on the medication’s potential to reduce the unpleasant symptoms of mania, including irritability, insomnia, anxiety, and racing thoughts. At the first visit, dis­cuss setting boundaries with the patient to reduce mania-driven, intrusive phone calls. A patient might develop insight after mania has resolved and he (she) can appre­ciate social or economic harm that occurred while manic. This discussion might foster adherence to maintenance treatment. Advise your patient to limit activities that may increase stimulation and perpetuate the mania, such as exercise, parties, concerts, or crowded shopping malls. Also, recommend that your patient stop working temporarily, to reduce stress and prevent any manic-driven interactions that could result in job loss.

If your patient has an established relationship with a psychotherapist, discuss with the therapist the plan to initiate mania treatment in the outpatient setting and work as a collaborative team, assuming that the patient has granted permission to share information. Encourage the therapist to increase the frequency of sessions with the patient to enable greater monitoring of changes in the patient’s manic symptoms. 

Family involvement
Family support is crucial when treating mania in the outpatient setting. Lacking insight and organization, manic patients require the “auxiliary” judgment of trusted family members to ensure treatment suc­cess. The family should identify a single person to act as the liaison between the family and the psychiatrist. The psychiatrist should instruct this individual to accom­pany the patient to each clinic visit and provide regular updates on the patient’s adherence to treatment, changes in symp­toms, and any new behaviors that would justify involuntary hospitalization. The treatment plan should be clearly communi­cated to this individual to ensure that it is implemented correctly. Ideally, this individ­ual would be someone who understands that bipolar disorder is a mental illness, who can tolerate the patient’s potential resentment of them for taking on this role, and who can influence the patient and the other family members to adhere to the treat­ment plan.

This family member also should watch the patient take medication to rule out nonadherence if the patient’s condition does not improve.

 

Provide extensive psychoeducation to the family (Table 3). Discuss these teaching points and their implications at length during the first visit and reinforce them at subsequent visits. Advise spouses that the acute manic period is not the time to make major decisions about their mar­riage or to engage in couple’s therapy. These options are better explored after the patient recovers from the manic episode.

Encourage the family to engage in mania harm-reduction techniques to the extent that the patient will allow (Table 4). In particu­lar, they should hold onto their loved one’s credit cards and checkbook, and discourage the patient from making any major finan­cial decisions until the mania has resolved. Additionally, patients should be relieved of childcare responsibilities during this period. If there are any child welfare safety con­cerns, the clinician will need to report this to authorities as required by local laws.

Advise family members or roommates to call emergency services and request a crisis intervention team, or to take the patient to an emergency room if he (she) makes ver­bal threats to harm themselves or others, is violent, or demonstrates behaviors that indicate that he is no longer able to care for himself. The psychiatrist should assist with completing Family and Medical Leave Act paperwork for family members who will monitor the patient at home, a work-excuse letter for the patient so he does not lose his job, and short-term disability paperwork to ensure income for the patient during the manic period.

These interventions can be challenging for the entire family system because they place family members in a paternalistic role and reduce the patient’s autonomy within the family. This is problematic when these role changes occur between spouses or between a patient-parent and his (her) children. Such changes typically need to be reversed over time and may require the help of a family or couple’s therapist. To support the psychological health of the patient’s family, refer them to the National Alliance on Mental Illness for family support groups or to individual psychotherapists.

Outpatient management can be rewarding
For “non-dangerous” manic patients who cannot be hospitalized involuntarily and refuse full or partial hospitalization, a psychiatrist must choose between beginning treatment in the clinic and referring the patient to another provider. The latter option is consistent with the APA’s ethical guidelines,³¹ but must be done appropriately to avoid legal liability.³² This decision may disappoint a family desperate to see their loved one recover quickly and may leave them feeling betrayed by the mental health system. On the other hand, choosing to treat mania in the outpatient setting can be rewarding when resolution of mania restores the family’s homeostasis.

To achieve this outcome, the outpatient psychiatrist must engage the patient’s fam­ily to ensure that the patient adheres to the treatment plan and monitor for potentially dangerous behavior. The psychiatrist also must use his knowledge of mood symp­toms, cognitive impairments, and the psy­chological experience of manic patients to create a safe and effective treatment strategy that the patient and family can implement.

Because of mania’s unpredictability and destructive potential, psychiatrists who agree to treat manic patients as outpatients should be familiar with their state’s statutes and case law that pertain to the refusal to accept a new patient, patient abandonment, involuntary hospitalization, confidentiality, and mandatory reporting. They also should seek clinical or legal consultation if they feel overwhelmed or uncertain about the safest and most legally sound approach.

Bottom Line
Treating mania in the outpatient setting is risky but can be accomplished in select patients with the help of the patient’s family and a strategy that integrates evidence-based pharmacotherapeutic and psychotherapeutic strategies. Because manic patients could display dangerous behavior, be familiar with your state’s laws regarding involuntary commitment, patient abandonment, and mandatory reporting.

Related Resources
• National Alliance on Mental Illness. www.NAMI.org.
• Depression and Bipolar Support Alliance. www.DBSAlliance.org.

Drug Brand Names
Aripiprazole • Abilify                                      Mirtazapine • Remeron
Asenapine • Saphris                                      Olanzapine • Zyprexa
Carbamazepine • Equetro, Tegretol                Pregabalin • Lyrica
Chlorpromazine • Thorazine                           Quetiapine • Seroquel
Clonazepam • Klonopin                                  Risperidone • Risperdal
Diphrenhydramine • Benadryl                         Trazodone • Desyrel
Eszopiclone • Lunesta                                    Valproate • Divalproex
Gabapentin • Neurontin                                  Zaleplon • Sonata
Lamotrigine • Lamictal                                    Ziprasidone •  Geodon
Lithium • Eskalith, Lithobid                              Zolpidem •  Ambien
Lorazepam • Ativan

 

Acknowledgement
The authors thank Peter Ash, MD, for carefully reviewing this manuscript and providing feedback.

Disclosures
Dr. Rakofsky receives research or grant support from Takeda. Dr. Dunlop receives research or grant support from Forest, GlaxoSmithKline, and Otsuka.

Manic episodes, by definition, are associated with significant social or occupational impairment.¹ Some manic patients are violent or engage in reckless behaviors that can harm themselves or others, such as speeding, disrupting traffic, or playing with fire. When these patients present to a psychiatrist’s outpatient practice, involuntary hospitalization might be justified.

However, some manic patients, in spite of their elevated, expansive, or irritable mood state, never behave dangerously and might not meet legal criteria for involuntary hospitalization, although these criteria differ from state to state. These patients might see a psychiatrist because manic symptoms such as irritability, talkativeness, and impulsivity are bother­some to their family members but pose no serious danger (Box). In this situation, the psychiatrist can strongly encourage the patient to seek voluntary hospitalization or attend a partial hospitalization program. If the patient declines, the psychiatrist is left with 2 choices: initiate treatment in the outpatient setting or refuse to treat the patient and refer to another provider.

Treating “non-dangerous” mania in the outpatient setting is fraught with challenges:
   • the possibility that the patient’s condition will progress to dangerousness
   • poor adherence to treatment because of the patient’s limited insight
   • the large amount of time required from the psychiatrist and care team to adequately manage the manic episode (eg, time spent with fam­ily members, frequent patient visits, and managing communications from the patient).

There are no guidelines to assist the office-based practitioner in treating mania in the outpatient setting. When considering dosing and optimal medication combina­tions for treating mania, clinical trials may be of limited value because most of these studies only included hospitalized manic patients.

Because of this dearth of knowledge, we provide recommendations based on our review of the literature and from our expe­rience working with manic patients who refuse voluntary hospitalization and could not be hospitalized against their will. These recommendations are organized into 3 sec­tions: diagnostic approach, treatment strat­egy, and family involvement.

Diagnostic approach
Making a diagnosis of mania might seem straightforward for clinicians who work in inpatient settings; however, mania might not present with classic florid symptoms among outpatients. Patients might have a chief concern of irritability, dysphoria, anxiety, or “insomnia,” which may lead clinicians to focus initially on non-bipolar conditions.²

During the interview, it is important to assess for any current DSM-5 symptoms of a manic episode, while being careful not to accept a patient’s denial of symptoms. Patients with mania often have poor insight and are unaware of changes from their base­line state when manic.³ Alternatively, manic patients may want you to believe that they are well and could minimize or deny all symptoms. Therefore, it is important to pay attention to mental status examination find­ings, such as hyperverbal speech, elated affect, psychomotor agitation, a tangential thought process, or flight of ideas.

Countertransference feelings of diagnos­tic confusion or frustration after long patient monologues or multiple interruptions by the patient should be incorporated into the diagnostic assessment. Family members or friends often can provide objective obser­vations of behavioral changes necessary to secure the diagnosis.

Treatment strategy
Decision points. When treating manic out­patients, assess the need for hospitalization at each visit. Advantages of the inpatient setting include:
   • the possibility of rapid medication adjustments
   • continuous observation to ensure the patient’s safety
   • keeping the patient temporarily removed from his community to prevent irrevers­ible social and economic harms.

However, a challenge with hospitaliza­tion is third-party payers’ influence on a patient’s length of stay, which may lead to rapid medication changes that may not be clinically ideal.

At each outpatient visit, explore with the patient and family emerging symptoms that could justify involuntary hospitaliza­tion. Document whether you recommended inpatient hospitalization, the patient’s response to the recommendation, that you are aware and have considered the risks associated with outpatient care, and that you have discussed these risks with the patient and family.

For patients well-known to the psychia­trist, a history of dangerous mania may lead him (her) to strongly recommend hos­pitalization, whereas a pre-existing thera­peutic alliance and no current or distant history of dangerous mania may lead the clinician to look for alternatives to inpatient care. Concomitant drug or alcohol use may increase the likelihood of mania becoming dangerous, making outpatient treatment ill-advised and riskier for everyone involved.

In exchange for agreeing to provide out­patient care for mania, it often is helpful to negotiate with the patient and family a threshold level of symptoms or behavior that will result in the patient agreeing to voluntary hospitalization (Table 1). Such an agreement can include stopping outpatient treatment if the patient does not improve significantly after 2 or 3 weeks or develops psychotic symptoms. The negotiation also can include partial hospitalization as an option, so long as the patient’s mania con­tinues to be non-dangerous.

 

Obtaining pretreatment blood work can help a clinician determine whether a medication is safe to prescribe and establish causality if laboratory abnormalities arise after treatment begins. Ideally, the psychia­trist should follow consensus guidelines developed by the International Society for Bipolar Disorders⁴ or the American Psychiatric Association (APA)⁵ and order appropriate laboratory tests before prescrib­ing anti-manic medications. Determine the pregnancy status of female patients of child-bearing age before prescribing a potentially teratogenic medication, especially because mania is associated with increased libido.⁶

Manic patients might be too disorga­nized to follow up with recommendations for laboratory testing, or could wait sev­eral days before completing blood work. Although not ideal, to avoid delaying treat­ment, a clinician might need to prescribe medication at the initial office visit, without pretreatment laboratory results. When the patient is more organized, complete the blood work. Keeping home pregnancy tests in the office can help rule out pregnancy before prescribing medication.

Medication. Meta-analyses have estab­lished the efficacy of mood stabilizers and antipsychotics for treating mania,^7,8 and sev­eral consensus guidelines have incorporated these findings into treatment algorithms.⁹

For a patient already taking medications recommended by the guidelines, assess treatment adherence during the initial inter­view by questioning the patient and family. When the logistics of phlebotomy permit, obtaining the blood level of psychotropics can show the presence of any detectable drug concentration, which demonstrates that the patient has taken the medication recently.

If there is no evidence of nonadherence, an initial step might be to increase the dos­age of the antipsychotic or mood stabilizer that the patient is already taking, ensuring that the dosage is optimized based on FDA indications and clinical trials data. The rec­ommended rate of dosage adjustments dif­fers among medications; however, optimal dosing should be reached quickly because a World Federation of Societies of Biological Psychiatry task force recommends that a mania treatment trial not exceed 2 weeks.¹⁰

Dosage increases can be made at weekly visits or sooner, based on treatment response and tolerability. If there is no ben­efit after optimizing the dosage, the next step would be to add a mood stabilizer to a second-generation antipsychotic (SGA), or vice versa to promote additive or syn­ergistic medication effects.¹¹ Switching one medication for the other should be avoided unless there are tolerability concerns.

For a patient who is not taking any medi­cations, select a treatment that balances rapid stabilization with long-term efficacy and tolerability. Table 2 lists FDA-approved treatments for mania. Lamotrigine provides prophylactic efficacy with few associated risks, but it has no anti-manic effects and would be a poor choice for most actively manic patients. Most studies indicate that antipsychotics work faster than lithium at the 1-week mark; however, this may be a function of the lithium titration schedule followed in the protocols, the severity of mania among enrolled patients, the inclu­sion of typically non-responsive manic patients (eg, mixed) in the analysis, and the antipsychotic’s sedative potential rela­tive to lithium. Although the anti-manic and prophylactic potential of lithium and valproate might make them an ideal first-line option, antipsychotics could stabilize a manic patient faster, especially if agitation is present.^12,13

Breaking mania quickly is important when treating patients in the outpatient set­ting. In these situations, a reasonable choice is to prescribe a SGA, because of their rapid onset of effect, low potential for switch to depression, and utility in treating classic, mixed, or psychotic mania.¹⁰ Oral loading of valproate (20 mg/kg) is another option. An inpatient study that used an oral-loading strategy demonstrated a similar time to response as olanzapine,¹⁴ in contrast to an inpatient¹⁵ and an outpatient study¹⁶ that employed a standard starting dosage for each patient and led to slower improve­ment compared with olanzapine.

SGAs should be dosed moderately and lower than if the patient were hospitalized, to avoid alienating the patient from treat­ment by causing intolerable side effects. In particular, patients and their families should be warned about immediate risks, such as orthostasis or extrapyramidal symptoms. Although treatment guidelines recommend combination therapy as a possible first-line option,⁹ in the outpatient setting, monother­apy with an optimally dosed, rapid-acting agent is preferred to promote medication adherence and avoid potentially danger­ous sedation. Manic patients experience increased distractibility and verbal memory and executive function impairments that can interfere with medication adherence.¹⁷ Therefore, patients are more likely to fol­low a simpler regimen. If SGA or valpro­ate monotherapy does not control mania, begin combination treatment with a mood stabilizer and SGA. If the patient experi­ences remission with SGA monotherapy, the risks and benefits of maintaining the SGA vs switching to a mood stabilizer can be discussed.

 

Provide medication “as needed” for agitation—additional SGA dosing or a benzodiazepine—and explain to fam­ily members when their use is warranted. Benzodiazepines can provide short-term benefits for manic patients: anxiety relief, sedation, and anti-manic efficacy as mono­therapy^18-20 and in combination with other medications.²¹ Studies showing mono­therapy efficacy employed high dosages of benzodiazepines (lorazepam mean dos­age, 14 mg/d; clonazepam mean dosage, 13 mg/d)¹⁹ and high dosages of antipsy­chotics as needed,^18,20 and often were associ­ated with excessive sedation and ataxia.^18,19 This makes benzodiazepine monotherapy a potentially dangerous approach for out­patient treatment of mania. IM lorazepam treated manic agitation less quickly than IM olanzapine, suggesting that SGAs are preferable in the outpatient setting because rapid control of agitation is crucial.²² If pre­scribed, a trusted family member should dispense benzodiazepines to the patient to minimize misuse because of impulsivity, distractibility, desperation to sleep, or plea­sure seeking.

SGAs have the benefit of sedation but occasionally additional sleep medica­tions are required. Benzodiazepine recep­tor agonists (BzRAs), such as zolpidem, eszopiclone, and zaleplon, should be used with caution. Although these medicines are effective in treating insomnia in indi­viduals with primary insomnia²³ and major depression,²⁴ they have not been studied in manic patients. The decreased need for sleep in mania is phenomenologically²⁵ and perhaps biologically different than insomnia in major depression.²⁶ Therefore, mania-associated sleep disturbance might not respond to BZRAs. BzRAs also might induce somnambulism and other parasom­nias,²⁷ especially when used in combination with psychotropics, such as valproate²⁸; it is unclear if the manic state itself increases this risk further. Sedating antihistamines with anticholinergic blockade, such as diphenhydramine and low dosages (<100 mg/d) of quetiapine, are best used only in combination with anti-manic medi­cations because of putative link between anticholinergic blockade and manic induc­tion.²⁹ Less studied but safer options include novel anticonvulsants (gabapen­tin, pregabalin), melatonin, and melatonin receptor agonists. Sedating antidepressants, such as mirtazapine and trazodone, should be avoided.²⁵

Important adjunctive treatment steps include discontinuing all pro-manic agents, including antidepressants, stimulants, and steroids, and discouraging use of caffeine, energy drinks, illicit drugs, and alcohol. The patient should return for office visits at least weekly, and possibly more frequently, depending on severity. Telephone check-in calls between scheduled visits may be nec­essary until the mania is broken.

Psychotherapy. Other than supportive therapy and psychoeducation, other forms of psychotherapy during mania are not indicated. Psychotherapy trials in bipolar disorder do not inform anti-manic efficacy because few have enrolled acutely manic patients and most report long-term benefits rather than short-term efficacy for the index manic episode.³⁰ Educate patients about the importance of maintaining regular social rhythms and taking medication as pre­scribed. Manic patients might not be aware that they are acting differently during manic episodes, therefore efforts to improve the patient’s insight are unlikely to succeed. More time should be spent emphasizing the importance of adherence to treatment and taking anti-manic medications as pre­scribed. This discussion can be enhanced by focusing on the medication’s potential to reduce the unpleasant symptoms of mania, including irritability, insomnia, anxiety, and racing thoughts. At the first visit, dis­cuss setting boundaries with the patient to reduce mania-driven, intrusive phone calls. A patient might develop insight after mania has resolved and he (she) can appre­ciate social or economic harm that occurred while manic. This discussion might foster adherence to maintenance treatment. Advise your patient to limit activities that may increase stimulation and perpetuate the mania, such as exercise, parties, concerts, or crowded shopping malls. Also, recommend that your patient stop working temporarily, to reduce stress and prevent any manic-driven interactions that could result in job loss.

If your patient has an established relationship with a psychotherapist, discuss with the therapist the plan to initiate mania treatment in the outpatient setting and work as a collaborative team, assuming that the patient has granted permission to share information. Encourage the therapist to increase the frequency of sessions with the patient to enable greater monitoring of changes in the patient’s manic symptoms. 

Family involvement
Family support is crucial when treating mania in the outpatient setting. Lacking insight and organization, manic patients require the “auxiliary” judgment of trusted family members to ensure treatment suc­cess. The family should identify a single person to act as the liaison between the family and the psychiatrist. The psychiatrist should instruct this individual to accom­pany the patient to each clinic visit and provide regular updates on the patient’s adherence to treatment, changes in symp­toms, and any new behaviors that would justify involuntary hospitalization. The treatment plan should be clearly communi­cated to this individual to ensure that it is implemented correctly. Ideally, this individ­ual would be someone who understands that bipolar disorder is a mental illness, who can tolerate the patient’s potential resentment of them for taking on this role, and who can influence the patient and the other family members to adhere to the treat­ment plan.

This family member also should watch the patient take medication to rule out nonadherence if the patient’s condition does not improve.

 

Provide extensive psychoeducation to the family (Table 3). Discuss these teaching points and their implications at length during the first visit and reinforce them at subsequent visits. Advise spouses that the acute manic period is not the time to make major decisions about their mar­riage or to engage in couple’s therapy. These options are better explored after the patient recovers from the manic episode.

Encourage the family to engage in mania harm-reduction techniques to the extent that the patient will allow (Table 4). In particu­lar, they should hold onto their loved one’s credit cards and checkbook, and discourage the patient from making any major finan­cial decisions until the mania has resolved. Additionally, patients should be relieved of childcare responsibilities during this period. If there are any child welfare safety con­cerns, the clinician will need to report this to authorities as required by local laws.

Advise family members or roommates to call emergency services and request a crisis intervention team, or to take the patient to an emergency room if he (she) makes ver­bal threats to harm themselves or others, is violent, or demonstrates behaviors that indicate that he is no longer able to care for himself. The psychiatrist should assist with completing Family and Medical Leave Act paperwork for family members who will monitor the patient at home, a work-excuse letter for the patient so he does not lose his job, and short-term disability paperwork to ensure income for the patient during the manic period.

These interventions can be challenging for the entire family system because they place family members in a paternalistic role and reduce the patient’s autonomy within the family. This is problematic when these role changes occur between spouses or between a patient-parent and his (her) children. Such changes typically need to be reversed over time and may require the help of a family or couple’s therapist. To support the psychological health of the patient’s family, refer them to the National Alliance on Mental Illness for family support groups or to individual psychotherapists.

Outpatient management can be rewarding
For “non-dangerous” manic patients who cannot be hospitalized involuntarily and refuse full or partial hospitalization, a psychiatrist must choose between beginning treatment in the clinic and referring the patient to another provider. The latter option is consistent with the APA’s ethical guidelines,³¹ but must be done appropriately to avoid legal liability.³² This decision may disappoint a family desperate to see their loved one recover quickly and may leave them feeling betrayed by the mental health system. On the other hand, choosing to treat mania in the outpatient setting can be rewarding when resolution of mania restores the family’s homeostasis.

To achieve this outcome, the outpatient psychiatrist must engage the patient’s fam­ily to ensure that the patient adheres to the treatment plan and monitor for potentially dangerous behavior. The psychiatrist also must use his knowledge of mood symp­toms, cognitive impairments, and the psy­chological experience of manic patients to create a safe and effective treatment strategy that the patient and family can implement.

Because of mania’s unpredictability and destructive potential, psychiatrists who agree to treat manic patients as outpatients should be familiar with their state’s statutes and case law that pertain to the refusal to accept a new patient, patient abandonment, involuntary hospitalization, confidentiality, and mandatory reporting. They also should seek clinical or legal consultation if they feel overwhelmed or uncertain about the safest and most legally sound approach.

Bottom Line
Treating mania in the outpatient setting is risky but can be accomplished in select patients with the help of the patient’s family and a strategy that integrates evidence-based pharmacotherapeutic and psychotherapeutic strategies. Because manic patients could display dangerous behavior, be familiar with your state’s laws regarding involuntary commitment, patient abandonment, and mandatory reporting.

Related Resources
• National Alliance on Mental Illness. www.NAMI.org.
• Depression and Bipolar Support Alliance. www.DBSAlliance.org.

Drug Brand Names
Aripiprazole • Abilify                                      Mirtazapine • Remeron
Asenapine • Saphris                                      Olanzapine • Zyprexa
Carbamazepine • Equetro, Tegretol                Pregabalin • Lyrica
Chlorpromazine • Thorazine                           Quetiapine • Seroquel
Clonazepam • Klonopin                                  Risperidone • Risperdal
Diphrenhydramine • Benadryl                         Trazodone • Desyrel
Eszopiclone • Lunesta                                    Valproate • Divalproex
Gabapentin • Neurontin                                  Zaleplon • Sonata
Lamotrigine • Lamictal                                    Ziprasidone •  Geodon
Lithium • Eskalith, Lithobid                              Zolpidem •  Ambien
Lorazepam • Ativan

 

Acknowledgement
The authors thank Peter Ash, MD, for carefully reviewing this manuscript and providing feedback.

Disclosures
Dr. Rakofsky receives research or grant support from Takeda. Dr. Dunlop receives research or grant support from Forest, GlaxoSmithKline, and Otsuka.

Manic episodes, by definition, are associated with significant social or occupational impairment.¹ Some manic patients are violent or engage in reckless behaviors that can harm themselves or others, such as speeding, disrupting traffic, or playing with fire. When these patients present to a psychiatrist’s outpatient practice, involuntary hospitalization might be justified.

However, some manic patients, in spite of their elevated, expansive, or irritable mood state, never behave dangerously and might not meet legal criteria for involuntary hospitalization, although these criteria differ from state to state. These patients might see a psychiatrist because manic symptoms such as irritability, talkativeness, and impulsivity are bother­some to their family members but pose no serious danger (Box). In this situation, the psychiatrist can strongly encourage the patient to seek voluntary hospitalization or attend a partial hospitalization program. If the patient declines, the psychiatrist is left with 2 choices: initiate treatment in the outpatient setting or refuse to treat the patient and refer to another provider.

Treating “non-dangerous” mania in the outpatient setting is fraught with challenges:
   • the possibility that the patient’s condition will progress to dangerousness
   • poor adherence to treatment because of the patient’s limited insight
   • the large amount of time required from the psychiatrist and care team to adequately manage the manic episode (eg, time spent with fam­ily members, frequent patient visits, and managing communications from the patient).

There are no guidelines to assist the office-based practitioner in treating mania in the outpatient setting. When considering dosing and optimal medication combina­tions for treating mania, clinical trials may be of limited value because most of these studies only included hospitalized manic patients.

Because of this dearth of knowledge, we provide recommendations based on our review of the literature and from our expe­rience working with manic patients who refuse voluntary hospitalization and could not be hospitalized against their will. These recommendations are organized into 3 sec­tions: diagnostic approach, treatment strat­egy, and family involvement.

Diagnostic approach
Making a diagnosis of mania might seem straightforward for clinicians who work in inpatient settings; however, mania might not present with classic florid symptoms among outpatients. Patients might have a chief concern of irritability, dysphoria, anxiety, or “insomnia,” which may lead clinicians to focus initially on non-bipolar conditions.²

During the interview, it is important to assess for any current DSM-5 symptoms of a manic episode, while being careful not to accept a patient’s denial of symptoms. Patients with mania often have poor insight and are unaware of changes from their base­line state when manic.³ Alternatively, manic patients may want you to believe that they are well and could minimize or deny all symptoms. Therefore, it is important to pay attention to mental status examination find­ings, such as hyperverbal speech, elated affect, psychomotor agitation, a tangential thought process, or flight of ideas.

Countertransference feelings of diagnos­tic confusion or frustration after long patient monologues or multiple interruptions by the patient should be incorporated into the diagnostic assessment. Family members or friends often can provide objective obser­vations of behavioral changes necessary to secure the diagnosis.

Treatment strategy
Decision points. When treating manic out­patients, assess the need for hospitalization at each visit. Advantages of the inpatient setting include:
   • the possibility of rapid medication adjustments
   • continuous observation to ensure the patient’s safety
   • keeping the patient temporarily removed from his community to prevent irrevers­ible social and economic harms.

However, a challenge with hospitaliza­tion is third-party payers’ influence on a patient’s length of stay, which may lead to rapid medication changes that may not be clinically ideal.

At each outpatient visit, explore with the patient and family emerging symptoms that could justify involuntary hospitaliza­tion. Document whether you recommended inpatient hospitalization, the patient’s response to the recommendation, that you are aware and have considered the risks associated with outpatient care, and that you have discussed these risks with the patient and family.

For patients well-known to the psychia­trist, a history of dangerous mania may lead him (her) to strongly recommend hos­pitalization, whereas a pre-existing thera­peutic alliance and no current or distant history of dangerous mania may lead the clinician to look for alternatives to inpatient care. Concomitant drug or alcohol use may increase the likelihood of mania becoming dangerous, making outpatient treatment ill-advised and riskier for everyone involved.

In exchange for agreeing to provide out­patient care for mania, it often is helpful to negotiate with the patient and family a threshold level of symptoms or behavior that will result in the patient agreeing to voluntary hospitalization (Table 1). Such an agreement can include stopping outpatient treatment if the patient does not improve significantly after 2 or 3 weeks or develops psychotic symptoms. The negotiation also can include partial hospitalization as an option, so long as the patient’s mania con­tinues to be non-dangerous.

 

Obtaining pretreatment blood work can help a clinician determine whether a medication is safe to prescribe and establish causality if laboratory abnormalities arise after treatment begins. Ideally, the psychia­trist should follow consensus guidelines developed by the International Society for Bipolar Disorders⁴ or the American Psychiatric Association (APA)⁵ and order appropriate laboratory tests before prescrib­ing anti-manic medications. Determine the pregnancy status of female patients of child-bearing age before prescribing a potentially teratogenic medication, especially because mania is associated with increased libido.⁶

Manic patients might be too disorga­nized to follow up with recommendations for laboratory testing, or could wait sev­eral days before completing blood work. Although not ideal, to avoid delaying treat­ment, a clinician might need to prescribe medication at the initial office visit, without pretreatment laboratory results. When the patient is more organized, complete the blood work. Keeping home pregnancy tests in the office can help rule out pregnancy before prescribing medication.

Medication. Meta-analyses have estab­lished the efficacy of mood stabilizers and antipsychotics for treating mania,^7,8 and sev­eral consensus guidelines have incorporated these findings into treatment algorithms.⁹

For a patient already taking medications recommended by the guidelines, assess treatment adherence during the initial inter­view by questioning the patient and family. When the logistics of phlebotomy permit, obtaining the blood level of psychotropics can show the presence of any detectable drug concentration, which demonstrates that the patient has taken the medication recently.

If there is no evidence of nonadherence, an initial step might be to increase the dos­age of the antipsychotic or mood stabilizer that the patient is already taking, ensuring that the dosage is optimized based on FDA indications and clinical trials data. The rec­ommended rate of dosage adjustments dif­fers among medications; however, optimal dosing should be reached quickly because a World Federation of Societies of Biological Psychiatry task force recommends that a mania treatment trial not exceed 2 weeks.¹⁰

Dosage increases can be made at weekly visits or sooner, based on treatment response and tolerability. If there is no ben­efit after optimizing the dosage, the next step would be to add a mood stabilizer to a second-generation antipsychotic (SGA), or vice versa to promote additive or syn­ergistic medication effects.¹¹ Switching one medication for the other should be avoided unless there are tolerability concerns.

For a patient who is not taking any medi­cations, select a treatment that balances rapid stabilization with long-term efficacy and tolerability. Table 2 lists FDA-approved treatments for mania. Lamotrigine provides prophylactic efficacy with few associated risks, but it has no anti-manic effects and would be a poor choice for most actively manic patients. Most studies indicate that antipsychotics work faster than lithium at the 1-week mark; however, this may be a function of the lithium titration schedule followed in the protocols, the severity of mania among enrolled patients, the inclu­sion of typically non-responsive manic patients (eg, mixed) in the analysis, and the antipsychotic’s sedative potential rela­tive to lithium. Although the anti-manic and prophylactic potential of lithium and valproate might make them an ideal first-line option, antipsychotics could stabilize a manic patient faster, especially if agitation is present.^12,13

Breaking mania quickly is important when treating patients in the outpatient set­ting. In these situations, a reasonable choice is to prescribe a SGA, because of their rapid onset of effect, low potential for switch to depression, and utility in treating classic, mixed, or psychotic mania.¹⁰ Oral loading of valproate (20 mg/kg) is another option. An inpatient study that used an oral-loading strategy demonstrated a similar time to response as olanzapine,¹⁴ in contrast to an inpatient¹⁵ and an outpatient study¹⁶ that employed a standard starting dosage for each patient and led to slower improve­ment compared with olanzapine.

SGAs should be dosed moderately and lower than if the patient were hospitalized, to avoid alienating the patient from treat­ment by causing intolerable side effects. In particular, patients and their families should be warned about immediate risks, such as orthostasis or extrapyramidal symptoms. Although treatment guidelines recommend combination therapy as a possible first-line option,⁹ in the outpatient setting, monother­apy with an optimally dosed, rapid-acting agent is preferred to promote medication adherence and avoid potentially danger­ous sedation. Manic patients experience increased distractibility and verbal memory and executive function impairments that can interfere with medication adherence.¹⁷ Therefore, patients are more likely to fol­low a simpler regimen. If SGA or valpro­ate monotherapy does not control mania, begin combination treatment with a mood stabilizer and SGA. If the patient experi­ences remission with SGA monotherapy, the risks and benefits of maintaining the SGA vs switching to a mood stabilizer can be discussed.

 

Provide medication “as needed” for agitation—additional SGA dosing or a benzodiazepine—and explain to fam­ily members when their use is warranted. Benzodiazepines can provide short-term benefits for manic patients: anxiety relief, sedation, and anti-manic efficacy as mono­therapy^18-20 and in combination with other medications.²¹ Studies showing mono­therapy efficacy employed high dosages of benzodiazepines (lorazepam mean dos­age, 14 mg/d; clonazepam mean dosage, 13 mg/d)¹⁹ and high dosages of antipsy­chotics as needed,^18,20 and often were associ­ated with excessive sedation and ataxia.^18,19 This makes benzodiazepine monotherapy a potentially dangerous approach for out­patient treatment of mania. IM lorazepam treated manic agitation less quickly than IM olanzapine, suggesting that SGAs are preferable in the outpatient setting because rapid control of agitation is crucial.²² If pre­scribed, a trusted family member should dispense benzodiazepines to the patient to minimize misuse because of impulsivity, distractibility, desperation to sleep, or plea­sure seeking.

SGAs have the benefit of sedation but occasionally additional sleep medica­tions are required. Benzodiazepine recep­tor agonists (BzRAs), such as zolpidem, eszopiclone, and zaleplon, should be used with caution. Although these medicines are effective in treating insomnia in indi­viduals with primary insomnia²³ and major depression,²⁴ they have not been studied in manic patients. The decreased need for sleep in mania is phenomenologically²⁵ and perhaps biologically different than insomnia in major depression.²⁶ Therefore, mania-associated sleep disturbance might not respond to BZRAs. BzRAs also might induce somnambulism and other parasom­nias,²⁷ especially when used in combination with psychotropics, such as valproate²⁸; it is unclear if the manic state itself increases this risk further. Sedating antihistamines with anticholinergic blockade, such as diphenhydramine and low dosages (<100 mg/d) of quetiapine, are best used only in combination with anti-manic medi­cations because of putative link between anticholinergic blockade and manic induc­tion.²⁹ Less studied but safer options include novel anticonvulsants (gabapen­tin, pregabalin), melatonin, and melatonin receptor agonists. Sedating antidepressants, such as mirtazapine and trazodone, should be avoided.²⁵

Important adjunctive treatment steps include discontinuing all pro-manic agents, including antidepressants, stimulants, and steroids, and discouraging use of caffeine, energy drinks, illicit drugs, and alcohol. The patient should return for office visits at least weekly, and possibly more frequently, depending on severity. Telephone check-in calls between scheduled visits may be nec­essary until the mania is broken.

Psychotherapy. Other than supportive therapy and psychoeducation, other forms of psychotherapy during mania are not indicated. Psychotherapy trials in bipolar disorder do not inform anti-manic efficacy because few have enrolled acutely manic patients and most report long-term benefits rather than short-term efficacy for the index manic episode.³⁰ Educate patients about the importance of maintaining regular social rhythms and taking medication as pre­scribed. Manic patients might not be aware that they are acting differently during manic episodes, therefore efforts to improve the patient’s insight are unlikely to succeed. More time should be spent emphasizing the importance of adherence to treatment and taking anti-manic medications as pre­scribed. This discussion can be enhanced by focusing on the medication’s potential to reduce the unpleasant symptoms of mania, including irritability, insomnia, anxiety, and racing thoughts. At the first visit, dis­cuss setting boundaries with the patient to reduce mania-driven, intrusive phone calls. A patient might develop insight after mania has resolved and he (she) can appre­ciate social or economic harm that occurred while manic. This discussion might foster adherence to maintenance treatment. Advise your patient to limit activities that may increase stimulation and perpetuate the mania, such as exercise, parties, concerts, or crowded shopping malls. Also, recommend that your patient stop working temporarily, to reduce stress and prevent any manic-driven interactions that could result in job loss.

If your patient has an established relationship with a psychotherapist, discuss with the therapist the plan to initiate mania treatment in the outpatient setting and work as a collaborative team, assuming that the patient has granted permission to share information. Encourage the therapist to increase the frequency of sessions with the patient to enable greater monitoring of changes in the patient’s manic symptoms. 

Family involvement
Family support is crucial when treating mania in the outpatient setting. Lacking insight and organization, manic patients require the “auxiliary” judgment of trusted family members to ensure treatment suc­cess. The family should identify a single person to act as the liaison between the family and the psychiatrist. The psychiatrist should instruct this individual to accom­pany the patient to each clinic visit and provide regular updates on the patient’s adherence to treatment, changes in symp­toms, and any new behaviors that would justify involuntary hospitalization. The treatment plan should be clearly communi­cated to this individual to ensure that it is implemented correctly. Ideally, this individ­ual would be someone who understands that bipolar disorder is a mental illness, who can tolerate the patient’s potential resentment of them for taking on this role, and who can influence the patient and the other family members to adhere to the treat­ment plan.

This family member also should watch the patient take medication to rule out nonadherence if the patient’s condition does not improve.

 

Provide extensive psychoeducation to the family (Table 3). Discuss these teaching points and their implications at length during the first visit and reinforce them at subsequent visits. Advise spouses that the acute manic period is not the time to make major decisions about their mar­riage or to engage in couple’s therapy. These options are better explored after the patient recovers from the manic episode.

Encourage the family to engage in mania harm-reduction techniques to the extent that the patient will allow (Table 4). In particu­lar, they should hold onto their loved one’s credit cards and checkbook, and discourage the patient from making any major finan­cial decisions until the mania has resolved. Additionally, patients should be relieved of childcare responsibilities during this period. If there are any child welfare safety con­cerns, the clinician will need to report this to authorities as required by local laws.

Advise family members or roommates to call emergency services and request a crisis intervention team, or to take the patient to an emergency room if he (she) makes ver­bal threats to harm themselves or others, is violent, or demonstrates behaviors that indicate that he is no longer able to care for himself. The psychiatrist should assist with completing Family and Medical Leave Act paperwork for family members who will monitor the patient at home, a work-excuse letter for the patient so he does not lose his job, and short-term disability paperwork to ensure income for the patient during the manic period.

These interventions can be challenging for the entire family system because they place family members in a paternalistic role and reduce the patient’s autonomy within the family. This is problematic when these role changes occur between spouses or between a patient-parent and his (her) children. Such changes typically need to be reversed over time and may require the help of a family or couple’s therapist. To support the psychological health of the patient’s family, refer them to the National Alliance on Mental Illness for family support groups or to individual psychotherapists.

Outpatient management can be rewarding
For “non-dangerous” manic patients who cannot be hospitalized involuntarily and refuse full or partial hospitalization, a psychiatrist must choose between beginning treatment in the clinic and referring the patient to another provider. The latter option is consistent with the APA’s ethical guidelines,³¹ but must be done appropriately to avoid legal liability.³² This decision may disappoint a family desperate to see their loved one recover quickly and may leave them feeling betrayed by the mental health system. On the other hand, choosing to treat mania in the outpatient setting can be rewarding when resolution of mania restores the family’s homeostasis.

To achieve this outcome, the outpatient psychiatrist must engage the patient’s fam­ily to ensure that the patient adheres to the treatment plan and monitor for potentially dangerous behavior. The psychiatrist also must use his knowledge of mood symp­toms, cognitive impairments, and the psy­chological experience of manic patients to create a safe and effective treatment strategy that the patient and family can implement.

Because of mania’s unpredictability and destructive potential, psychiatrists who agree to treat manic patients as outpatients should be familiar with their state’s statutes and case law that pertain to the refusal to accept a new patient, patient abandonment, involuntary hospitalization, confidentiality, and mandatory reporting. They also should seek clinical or legal consultation if they feel overwhelmed or uncertain about the safest and most legally sound approach.

Bottom Line
Treating mania in the outpatient setting is risky but can be accomplished in select patients with the help of the patient’s family and a strategy that integrates evidence-based pharmacotherapeutic and psychotherapeutic strategies. Because manic patients could display dangerous behavior, be familiar with your state’s laws regarding involuntary commitment, patient abandonment, and mandatory reporting.

Related Resources
• National Alliance on Mental Illness. www.NAMI.org.
• Depression and Bipolar Support Alliance. www.DBSAlliance.org.

Drug Brand Names
Aripiprazole • Abilify                                      Mirtazapine • Remeron
Asenapine • Saphris                                      Olanzapine • Zyprexa
Carbamazepine • Equetro, Tegretol                Pregabalin • Lyrica
Chlorpromazine • Thorazine                           Quetiapine • Seroquel
Clonazepam • Klonopin                                  Risperidone • Risperdal
Diphrenhydramine • Benadryl                         Trazodone • Desyrel
Eszopiclone • Lunesta                                    Valproate • Divalproex
Gabapentin • Neurontin                                  Zaleplon • Sonata
Lamotrigine • Lamictal                                    Ziprasidone •  Geodon
Lithium • Eskalith, Lithobid                              Zolpidem •  Ambien
Lorazepam • Ativan

 

Acknowledgement
The authors thank Peter Ash, MD, for carefully reviewing this manuscript and providing feedback.

Disclosures
Dr. Rakofsky receives research or grant support from Takeda. Dr. Dunlop receives research or grant support from Forest, GlaxoSmithKline, and Otsuka.

As explained in the first part of this article in the October 2014 issue of Current Psychiatry, assess­ing and managing suicide risk are complex, difficult tasks without clear-cut, easy solutions. The case-based, mul­tiple-choice self-test, with accompanying commentary, pre­sented here is designed to enhance one’s ability to provide care for patients at risk for suicide. Part 2 of this article poses the remaining 7 of 15 questions, which are based on clinical experience and the referenced work of others.

Question 9
Mr. N, age 62, will be discharged from the psychiatric unit tomor­row. He was admitted after an overdose suicide attempt. Mr. N was depressed after the loss of his business and was “treating” his depres­sion and anxiety with alcohol. He is successfully withdrawn from alcohol and responds to medication and supportive psychotherapy. During a family meeting with staff, Mr. N’s wife states that he keeps a gun by his bedside. Mr. N has improved and is eager to go home.

Before discharging Mr. N, the psychiatrist or staff should:
   a) instruct Mr. N to remove the gun from his bedside
   b) instruct his wife to remove the gun from the home
   c) instruct the wife to look for >1 gun
   d) instruct the wife, before Mr. N’s discharge, to call the staff once guns and
ammunition are safely removed according to the pre-arranged safety plan
   e) instruct the wife to lock up the gun in a place that is not known to the patient

The best response option is D
Guns in the home are associated with a sig­nificant increase in suicide. All patients at risk for suicide must be asked if guns are available at home or easily accessible else­where, or if they intend to purchase a gun. Gun safety management requires a collabor­ative team approach including the clinician, patient, and person designated responsible for removing guns from the home.¹ The responsible person should be required to call the clinician to confirm that the guns have been removed and secured according to the plan. The principles of gun safety manage­ment apply to outpatients, inpatients, and emergency patients, although implementa­tion varies according to the clinical setting.

Asking the patient to remove guns from the home is too risky. Guns must be safely secured before the patient is discharged. Asking a spouse, other family member, or partner is necessary. The person asked must be willing to remove guns and ammunition according to a pre-arranged plan requiring a callback upon completion. A callback is essential because a family member in denial may do nothing to remove the guns or lock or “hide” them in the home where they will be found by a determined suicidal patient. Guns may be available outside the home, such as in the car, at the work place, or for purchase.

The essence of gun safety management is verification. Trust but verify or, better yet, verify, then trust.

Question 10
A recently admitted 56-year-old inpatient was discovered wrapping a towel around her neck. She denied suicidal intent; however, the treat­ment team viewed the incident as a suicide rehearsal. She was placed on one-to-one close observation.

Inpatient suicides frequently occur:
   a) shortly after admission
   b) during staff shift changes
   c) at meal times
   d) shortly after discharge
   e) all of the above

The best response option is E
Inpatient suicides also occur at increased frequency when psychiatric residents fin­ish their rotations and in understaffed psychiatric units.² Undue delay in the evaluation of a newly admitted acute, high-risk patient might allow the patient to commit suicide.

Most patient suicides occur shortly after hospital discharge (a few hours, days, or weeks later). Appleby et al³ found that the highest number of suicides occurred during the first week after discharge. Meehan et al⁴ found that suicide occurred most frequently during the first 2 weeks post-discharge; the highest number of suicides occurred on the first day after discharge.

Question 11
Ms. G, a 43-year-old, single woman in acute sui­cide crisis, is admitted to the psychiatric unit of a general hospital. She is diagnosed with bipolar I disorder, most recent episode depressed, and borderline personality disorder. She has had multiple psychiatric hospitalizations, all pre­cipitated by a suicide crisis. The average length of stay on the psychiatric unit is 6.3 days. After 7 days of intensive treatment, Ms. G is stabilized and suicide risk is reduced. The treatment team prepares for her discharge.

Ms. G’s suicide risk at discharge is most likely at:
   a) indeterminate risk
   b) low risk
   c) moderate risk
   d) chronic high risk
   e) acute high risk

 

The best response option is D
The length of stay in many acute care psy­chiatric facilities is <7 days. The goal of hospitalization is to stabilize the patient and discharge to appropriate community mental health resources. Discharge plan­ning begins at the time of admission.

Reducing Ms. G’s suicide risk to low or moderate is unlikely because of her diagnoses, frequent hospitalizations, and acute high risk for suicide on admission. After acute, high-risk suicidal patients are treated, many revert to chronic high risk for suicide.

Patients at chronic high risk for suicide often are treated as outpatients, except when an acute suicidal crisis requires hospi­talization.⁵ At discharge from the hospital, the goal is to return the patient to outpatient treatment.

A discharge note identifies the acute sui­cide risk factors that have abated and the chronic (long-term) suicide risk factors that remain. The discharge note also addresses a patient’s chronic vulnerability to suicide. For example, a patient can become acutely suicidal again, depending on a number of factors, including the nature and cause of the psychiatric illness, adequacy of future treat­ment, adherence to treatment recommenda­tions, and unforeseeable life vicissitudes.

Question 12
A 20-year-old college student is hospitalized after an overdose suicide attempt. Failing grades, panic attacks, and depression precipitated the suicide attempt. After 8 days of hos­pitalization, she is much improved and ready for discharge. She is assessed to be at low to moderate suicide risk. The treating psychiatrist and social worker convene a family meet­ing with both parents and an older brother. The family’s role after discharge is discussed.

All of the following options are helpful family roles except:
   a) provide constant 24-hour family supervision
   b) provide emotional support
   c) observe and report symptoms and behaviors of concern
   d) encourage adherence with treatment
   e) provide helpful feedback about the patient’s thoughts and behavior

The best response option is A
The family’s role is important, but it is not a substitute for constant safety management provided by trained mental health profes­sionals on an inpatient psychiatric unit.⁵ Early discharge of an inpatient by relying on family supervision can be precarious. Most inpatients are discharged at some level of suicide risk, given the short length of hos­pital stay. If an outpatient at risk of suicide requires constant 24-hour family supervi­sion, then psychiatric hospitalization is indicated.

Patients who are intent on killing them­selves can find ingenious ways to attempt or commit suicide. Asking family members to keep a constant watch often fails. Most family members will not follow the patient into the bathroom or be able to stay up all night to observe the patient. Moreover, fam­ily members find reasons to make exceptions to constant surveillance because of denial, fatigue, or the need to attend to other press­ing matters.


Question 13
During the initial evaluation of a patient, it is the psychiatrist’s practice to routinely inquire about current and past suicide ideation. An affirma­tive answer prompts a systematic suicide risk assessment. In the absence of current risk, if exploration of the patient’s history reveals chronic suicide risk factors, the psychiatrist con­ducts a systematic suicide risk assessment.

The chronic risk factor that has the highest association with suicide is:
   a) family history of mental illness or suicide
   b) childhood abuse
   c) history of a suicide attempt
   d) impulsivity or aggression
   e) prior psychiatric hospitalization

The best response option is C
A comprehensive suicide risk assessment may not be required at the initial outpatient evaluation in the absence of acute suicide risk factors. However, chronic suicide risk factors may be present.

The Standard Mortality Ratio (SMR) for prior suicide attempts by any method was 38.61.⁶ Suicide risk was highest in the 2 years after the first attempt. The SMR is a measure of the relative risk of suicide compared with the expected rate in the general population (SMR of 1).

Some chronic suicide risk factors are static: for example, a family history of psy­chiatric illness or earlier suicide attempt. Other chronic risk factors, usually a trait characteristic, can become acute: for exam­ple, impulsivity or aggression, or deliberate self-harm. The presence of chronic suicide risk factors should prompt a systematic sui­cide risk assessment. Evaluation of chronic suicide risk factors is an essential component of comprehensive assessment.5

Question 14
A psychiatrist is treating Dr. R, a 43-year-old physician, for anxiety and depression. The psychiatrist sees Dr. R twice a week for psy­chotherapy and medication management. A recent lawsuit filed against Dr. R has severely exacerbated her symptoms. She can sleep for only a few hours. Suicide ideation has emerged, frightening Dr. R and her family. The psychiatrist performs a systematic suicide risk assessment and determines that Dr. R is at acute high risk for suicide.

The psychiatrist recommends immediate hospitalization, but Dr. R adamantly refuses. The psychiatrist decides not to involuntarily hospitalize her because she does not meet the substantive criteria of the state involun­tary commitment statute (eg, overt suicidal behaviors). The psychiatrist chooses to con­tinue outpatient treatment.

 

Clinical interventions to reduce Dr. R’s suicide risk include:
   a) see her more often
   b) adjust medications
   c) obtain a consult
   d) refer her to an intensive outpatient program
   e) all of the above

The best response option is E
To hospitalize or not to hospitalize— that is the conundrum that psychiatrists often face with high-risk suicidal patients. The decision is more complicated when the need for hospitalization is clear but the patient refuses. The decisions that the psychiatrist makes at this point are crucial for treatment and risk management.⁵

If the patient disagrees with the psychiatrist’s recommendation to hospitalize, refusal should be addressed as a treatment issue. When the need for hospitalization is acute, a prolonged inquiry is not possible. In addition, the therapeutic alliance may become strained. This clinical situation tries a clinician’s professional mettle.

Consultation and referral are options to consider if time and the patient’s condition allows. A psychiatric clinician should never worry alone; sleepless nights benefit neither the psychiatrist nor the patient.

As Dr. R’s case shows, a psychiatrist might decide not to hospitalize a patient who is assessed to be at moderate or high risk of suicide. Protective factors may allow continuing outpatient treatment. A good therapeutic alliance may be present if the psychiatrist has worked with the patient for some time. Family support also may be available.

The clinician must determine if the patient’s suicide risk can be managed by more frequent visits and treatment adjust­ments. Also, supportive family members can help by providing observational data. Protective factors can be overwhelmed by a severe mental illness. In contrast, a patient assessed as being at moderate risk of suicide might need to be hospitalized when protec­tive factors are few or absent.

The psychiatrist may determine that a patient at high risk of suicide who refuses hospitalization does not meet criteria for involuntary hospitalization. For example, criteria might require that the patient must have made a suicide attempt within a speci­fied period of time. States have provisions in their commitment statutes granting immu­nity from liability if the clinician uses reason­able clinical judgment and acts in good faith when involuntarily hospitalizing a patient.⁷ 

Question 15
Mr. U, a 39-year-old, married engineer, is ready to be discharged from the inpatient unit. He was admitted 7 days earlier for acute alco­hol intoxication and suicidal threats. He has undergone successful detoxification. Mr. U has had 2 similar episodes within the past year.

The treatment team conducts a risk-benefit analysis for both discharge and continued hospi­talization. A consultation also is obtained.

The discharge decision will be most influenced by:
   a) presence of family support
   b) compliance with follow-up care
   c) availability of dual diagnosis programs
   d) systematic suicide risk assessment
   e) consultation


The best response option is D
All of the options in Question 15 concerning discharge planning of patients at risk for sui­cide are important. However, conducting a systematic suicide risk assessment to inform discharge planning is the most critical. Mr. U had 2 previous psychiatric admissions for alcohol abuse and suicidal ideation. He is a chronic suicide risk who becomes high risk when intoxicated.

Discharge planning begins at admission and is refined during the patient’s stay. Before a patient is discharged, a final post-discharge treatment and aftercare plan is necessary. After discharge, suicide risk increases as the intensity of treatment decreases.⁸

The patient’s willingness to cooperate with discharge and aftercare planning is critical in establishing contact with follow-up treat­ers. The treatment team should structure the follow-up plan to encourage compliance. For example, psychotic patients at risk of suicide who have a history of stopping medications after discharge can be given a long-acting IM antipsychotic that will last until they reach aftercare. Patients with comorbid drug and alcohol abuse disorders are referred to agen­cies equipped to manage dual-diagnosis patients.

Psychiatrists’ ability to ensure follow-up treatment is limited, a fact that must be acknowledged by the psychiatric and legal communities. Beyond patient stabilization, a clinician’s options to bring about posi­tive changes can be limited or nonexistent. Also, the patient’s failure to adhere to post-discharge plans and treatment often leads to rehospitalization, hopelessness, and greater suicide risk.

Psychiatric patients at moderate or moderate-to-high risk for suicide increas­ingly are treated in outpatient settings. It is the responsibility of the clinician and the treatment team to competently hand off the patient to appropriate outpatient aftercare. With the patient’s permission, the psychia­trist or social worker should call the follow-up agency or therapist before discharge to provide information about the patient’s diagnosis, treatment, and hospital course.

Last, follow-up appointments should be made as close to the time of discharge as possible. Suicide often occurs on the first day after discharge.³

 

Bottom Line
Fully commit time and effort to the ongoing assessment, treatment, and management of patients at suicide risk. Suicide risk assessment is a process, not an event. Conduct a suicide risk assessment at important clinical junctures (eg, initial evaluation, discharge, changing observation levels). Contemporaneously, document suicide risk assessments. This self-assessment helps clinicians gauge their strengths and identify skills that need further development.

Disclosure
Dr. Simon reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Simon is the co-editor of The American Psychiatry Publishing textbook of Suicide Assessment and Management, 2nd edition, from which this article is adapted, by permission of the publisher, American Psychiatry Publishing, Inc. ©2012.

As explained in the first part of this article in the October 2014 issue of Current Psychiatry, assess­ing and managing suicide risk are complex, difficult tasks without clear-cut, easy solutions. The case-based, mul­tiple-choice self-test, with accompanying commentary, pre­sented here is designed to enhance one’s ability to provide care for patients at risk for suicide. Part 2 of this article poses the remaining 7 of 15 questions, which are based on clinical experience and the referenced work of others.

Question 9
Mr. N, age 62, will be discharged from the psychiatric unit tomor­row. He was admitted after an overdose suicide attempt. Mr. N was depressed after the loss of his business and was “treating” his depres­sion and anxiety with alcohol. He is successfully withdrawn from alcohol and responds to medication and supportive psychotherapy. During a family meeting with staff, Mr. N’s wife states that he keeps a gun by his bedside. Mr. N has improved and is eager to go home.

Before discharging Mr. N, the psychiatrist or staff should:
   a) instruct Mr. N to remove the gun from his bedside
   b) instruct his wife to remove the gun from the home
   c) instruct the wife to look for >1 gun
   d) instruct the wife, before Mr. N’s discharge, to call the staff once guns and
ammunition are safely removed according to the pre-arranged safety plan
   e) instruct the wife to lock up the gun in a place that is not known to the patient

The best response option is D
Guns in the home are associated with a sig­nificant increase in suicide. All patients at risk for suicide must be asked if guns are available at home or easily accessible else­where, or if they intend to purchase a gun. Gun safety management requires a collabor­ative team approach including the clinician, patient, and person designated responsible for removing guns from the home.¹ The responsible person should be required to call the clinician to confirm that the guns have been removed and secured according to the plan. The principles of gun safety manage­ment apply to outpatients, inpatients, and emergency patients, although implementa­tion varies according to the clinical setting.

Asking the patient to remove guns from the home is too risky. Guns must be safely secured before the patient is discharged. Asking a spouse, other family member, or partner is necessary. The person asked must be willing to remove guns and ammunition according to a pre-arranged plan requiring a callback upon completion. A callback is essential because a family member in denial may do nothing to remove the guns or lock or “hide” them in the home where they will be found by a determined suicidal patient. Guns may be available outside the home, such as in the car, at the work place, or for purchase.

The essence of gun safety management is verification. Trust but verify or, better yet, verify, then trust.

Question 10
A recently admitted 56-year-old inpatient was discovered wrapping a towel around her neck. She denied suicidal intent; however, the treat­ment team viewed the incident as a suicide rehearsal. She was placed on one-to-one close observation.

Inpatient suicides frequently occur:
   a) shortly after admission
   b) during staff shift changes
   c) at meal times
   d) shortly after discharge
   e) all of the above

The best response option is E
Inpatient suicides also occur at increased frequency when psychiatric residents fin­ish their rotations and in understaffed psychiatric units.² Undue delay in the evaluation of a newly admitted acute, high-risk patient might allow the patient to commit suicide.

Most patient suicides occur shortly after hospital discharge (a few hours, days, or weeks later). Appleby et al³ found that the highest number of suicides occurred during the first week after discharge. Meehan et al⁴ found that suicide occurred most frequently during the first 2 weeks post-discharge; the highest number of suicides occurred on the first day after discharge.

Question 11
Ms. G, a 43-year-old, single woman in acute sui­cide crisis, is admitted to the psychiatric unit of a general hospital. She is diagnosed with bipolar I disorder, most recent episode depressed, and borderline personality disorder. She has had multiple psychiatric hospitalizations, all pre­cipitated by a suicide crisis. The average length of stay on the psychiatric unit is 6.3 days. After 7 days of intensive treatment, Ms. G is stabilized and suicide risk is reduced. The treatment team prepares for her discharge.

Ms. G’s suicide risk at discharge is most likely at:
   a) indeterminate risk
   b) low risk
   c) moderate risk
   d) chronic high risk
   e) acute high risk

 

The best response option is D
The length of stay in many acute care psy­chiatric facilities is <7 days. The goal of hospitalization is to stabilize the patient and discharge to appropriate community mental health resources. Discharge plan­ning begins at the time of admission.

Reducing Ms. G’s suicide risk to low or moderate is unlikely because of her diagnoses, frequent hospitalizations, and acute high risk for suicide on admission. After acute, high-risk suicidal patients are treated, many revert to chronic high risk for suicide.

Patients at chronic high risk for suicide often are treated as outpatients, except when an acute suicidal crisis requires hospi­talization.⁵ At discharge from the hospital, the goal is to return the patient to outpatient treatment.

A discharge note identifies the acute sui­cide risk factors that have abated and the chronic (long-term) suicide risk factors that remain. The discharge note also addresses a patient’s chronic vulnerability to suicide. For example, a patient can become acutely suicidal again, depending on a number of factors, including the nature and cause of the psychiatric illness, adequacy of future treat­ment, adherence to treatment recommenda­tions, and unforeseeable life vicissitudes.

Question 12
A 20-year-old college student is hospitalized after an overdose suicide attempt. Failing grades, panic attacks, and depression precipitated the suicide attempt. After 8 days of hos­pitalization, she is much improved and ready for discharge. She is assessed to be at low to moderate suicide risk. The treating psychiatrist and social worker convene a family meet­ing with both parents and an older brother. The family’s role after discharge is discussed.

All of the following options are helpful family roles except:
   a) provide constant 24-hour family supervision
   b) provide emotional support
   c) observe and report symptoms and behaviors of concern
   d) encourage adherence with treatment
   e) provide helpful feedback about the patient’s thoughts and behavior

The best response option is A
The family’s role is important, but it is not a substitute for constant safety management provided by trained mental health profes­sionals on an inpatient psychiatric unit.⁵ Early discharge of an inpatient by relying on family supervision can be precarious. Most inpatients are discharged at some level of suicide risk, given the short length of hos­pital stay. If an outpatient at risk of suicide requires constant 24-hour family supervi­sion, then psychiatric hospitalization is indicated.

Patients who are intent on killing them­selves can find ingenious ways to attempt or commit suicide. Asking family members to keep a constant watch often fails. Most family members will not follow the patient into the bathroom or be able to stay up all night to observe the patient. Moreover, fam­ily members find reasons to make exceptions to constant surveillance because of denial, fatigue, or the need to attend to other press­ing matters.


Question 13
During the initial evaluation of a patient, it is the psychiatrist’s practice to routinely inquire about current and past suicide ideation. An affirma­tive answer prompts a systematic suicide risk assessment. In the absence of current risk, if exploration of the patient’s history reveals chronic suicide risk factors, the psychiatrist con­ducts a systematic suicide risk assessment.

The chronic risk factor that has the highest association with suicide is:
   a) family history of mental illness or suicide
   b) childhood abuse
   c) history of a suicide attempt
   d) impulsivity or aggression
   e) prior psychiatric hospitalization

The best response option is C
A comprehensive suicide risk assessment may not be required at the initial outpatient evaluation in the absence of acute suicide risk factors. However, chronic suicide risk factors may be present.

The Standard Mortality Ratio (SMR) for prior suicide attempts by any method was 38.61.⁶ Suicide risk was highest in the 2 years after the first attempt. The SMR is a measure of the relative risk of suicide compared with the expected rate in the general population (SMR of 1).

Some chronic suicide risk factors are static: for example, a family history of psy­chiatric illness or earlier suicide attempt. Other chronic risk factors, usually a trait characteristic, can become acute: for exam­ple, impulsivity or aggression, or deliberate self-harm. The presence of chronic suicide risk factors should prompt a systematic sui­cide risk assessment. Evaluation of chronic suicide risk factors is an essential component of comprehensive assessment.5

Question 14
A psychiatrist is treating Dr. R, a 43-year-old physician, for anxiety and depression. The psychiatrist sees Dr. R twice a week for psy­chotherapy and medication management. A recent lawsuit filed against Dr. R has severely exacerbated her symptoms. She can sleep for only a few hours. Suicide ideation has emerged, frightening Dr. R and her family. The psychiatrist performs a systematic suicide risk assessment and determines that Dr. R is at acute high risk for suicide.

The psychiatrist recommends immediate hospitalization, but Dr. R adamantly refuses. The psychiatrist decides not to involuntarily hospitalize her because she does not meet the substantive criteria of the state involun­tary commitment statute (eg, overt suicidal behaviors). The psychiatrist chooses to con­tinue outpatient treatment.

 

Clinical interventions to reduce Dr. R’s suicide risk include:
   a) see her more often
   b) adjust medications
   c) obtain a consult
   d) refer her to an intensive outpatient program
   e) all of the above

The best response option is E
To hospitalize or not to hospitalize— that is the conundrum that psychiatrists often face with high-risk suicidal patients. The decision is more complicated when the need for hospitalization is clear but the patient refuses. The decisions that the psychiatrist makes at this point are crucial for treatment and risk management.⁵

If the patient disagrees with the psychiatrist’s recommendation to hospitalize, refusal should be addressed as a treatment issue. When the need for hospitalization is acute, a prolonged inquiry is not possible. In addition, the therapeutic alliance may become strained. This clinical situation tries a clinician’s professional mettle.

Consultation and referral are options to consider if time and the patient’s condition allows. A psychiatric clinician should never worry alone; sleepless nights benefit neither the psychiatrist nor the patient.

As Dr. R’s case shows, a psychiatrist might decide not to hospitalize a patient who is assessed to be at moderate or high risk of suicide. Protective factors may allow continuing outpatient treatment. A good therapeutic alliance may be present if the psychiatrist has worked with the patient for some time. Family support also may be available.

The clinician must determine if the patient’s suicide risk can be managed by more frequent visits and treatment adjust­ments. Also, supportive family members can help by providing observational data. Protective factors can be overwhelmed by a severe mental illness. In contrast, a patient assessed as being at moderate risk of suicide might need to be hospitalized when protec­tive factors are few or absent.

The psychiatrist may determine that a patient at high risk of suicide who refuses hospitalization does not meet criteria for involuntary hospitalization. For example, criteria might require that the patient must have made a suicide attempt within a speci­fied period of time. States have provisions in their commitment statutes granting immu­nity from liability if the clinician uses reason­able clinical judgment and acts in good faith when involuntarily hospitalizing a patient.⁷ 

Question 15
Mr. U, a 39-year-old, married engineer, is ready to be discharged from the inpatient unit. He was admitted 7 days earlier for acute alco­hol intoxication and suicidal threats. He has undergone successful detoxification. Mr. U has had 2 similar episodes within the past year.

The treatment team conducts a risk-benefit analysis for both discharge and continued hospi­talization. A consultation also is obtained.

The discharge decision will be most influenced by:
   a) presence of family support
   b) compliance with follow-up care
   c) availability of dual diagnosis programs
   d) systematic suicide risk assessment
   e) consultation


The best response option is D
All of the options in Question 15 concerning discharge planning of patients at risk for sui­cide are important. However, conducting a systematic suicide risk assessment to inform discharge planning is the most critical. Mr. U had 2 previous psychiatric admissions for alcohol abuse and suicidal ideation. He is a chronic suicide risk who becomes high risk when intoxicated.

Discharge planning begins at admission and is refined during the patient’s stay. Before a patient is discharged, a final post-discharge treatment and aftercare plan is necessary. After discharge, suicide risk increases as the intensity of treatment decreases.⁸

The patient’s willingness to cooperate with discharge and aftercare planning is critical in establishing contact with follow-up treat­ers. The treatment team should structure the follow-up plan to encourage compliance. For example, psychotic patients at risk of suicide who have a history of stopping medications after discharge can be given a long-acting IM antipsychotic that will last until they reach aftercare. Patients with comorbid drug and alcohol abuse disorders are referred to agen­cies equipped to manage dual-diagnosis patients.

Psychiatrists’ ability to ensure follow-up treatment is limited, a fact that must be acknowledged by the psychiatric and legal communities. Beyond patient stabilization, a clinician’s options to bring about posi­tive changes can be limited or nonexistent. Also, the patient’s failure to adhere to post-discharge plans and treatment often leads to rehospitalization, hopelessness, and greater suicide risk.

Psychiatric patients at moderate or moderate-to-high risk for suicide increas­ingly are treated in outpatient settings. It is the responsibility of the clinician and the treatment team to competently hand off the patient to appropriate outpatient aftercare. With the patient’s permission, the psychia­trist or social worker should call the follow-up agency or therapist before discharge to provide information about the patient’s diagnosis, treatment, and hospital course.

Last, follow-up appointments should be made as close to the time of discharge as possible. Suicide often occurs on the first day after discharge.³

 

Bottom Line
Fully commit time and effort to the ongoing assessment, treatment, and management of patients at suicide risk. Suicide risk assessment is a process, not an event. Conduct a suicide risk assessment at important clinical junctures (eg, initial evaluation, discharge, changing observation levels). Contemporaneously, document suicide risk assessments. This self-assessment helps clinicians gauge their strengths and identify skills that need further development.

Disclosure
Dr. Simon reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Simon is the co-editor of The American Psychiatry Publishing textbook of Suicide Assessment and Management, 2nd edition, from which this article is adapted, by permission of the publisher, American Psychiatry Publishing, Inc. ©2012.

As explained in the first part of this article in the October 2014 issue of Current Psychiatry, assess­ing and managing suicide risk are complex, difficult tasks without clear-cut, easy solutions. The case-based, mul­tiple-choice self-test, with accompanying commentary, pre­sented here is designed to enhance one’s ability to provide care for patients at risk for suicide. Part 2 of this article poses the remaining 7 of 15 questions, which are based on clinical experience and the referenced work of others.

Question 9
Mr. N, age 62, will be discharged from the psychiatric unit tomor­row. He was admitted after an overdose suicide attempt. Mr. N was depressed after the loss of his business and was “treating” his depres­sion and anxiety with alcohol. He is successfully withdrawn from alcohol and responds to medication and supportive psychotherapy. During a family meeting with staff, Mr. N’s wife states that he keeps a gun by his bedside. Mr. N has improved and is eager to go home.

Before discharging Mr. N, the psychiatrist or staff should:
   a) instruct Mr. N to remove the gun from his bedside
   b) instruct his wife to remove the gun from the home
   c) instruct the wife to look for >1 gun
   d) instruct the wife, before Mr. N’s discharge, to call the staff once guns and
ammunition are safely removed according to the pre-arranged safety plan
   e) instruct the wife to lock up the gun in a place that is not known to the patient

The best response option is D
Guns in the home are associated with a sig­nificant increase in suicide. All patients at risk for suicide must be asked if guns are available at home or easily accessible else­where, or if they intend to purchase a gun. Gun safety management requires a collabor­ative team approach including the clinician, patient, and person designated responsible for removing guns from the home.¹ The responsible person should be required to call the clinician to confirm that the guns have been removed and secured according to the plan. The principles of gun safety manage­ment apply to outpatients, inpatients, and emergency patients, although implementa­tion varies according to the clinical setting.

Asking the patient to remove guns from the home is too risky. Guns must be safely secured before the patient is discharged. Asking a spouse, other family member, or partner is necessary. The person asked must be willing to remove guns and ammunition according to a pre-arranged plan requiring a callback upon completion. A callback is essential because a family member in denial may do nothing to remove the guns or lock or “hide” them in the home where they will be found by a determined suicidal patient. Guns may be available outside the home, such as in the car, at the work place, or for purchase.

The essence of gun safety management is verification. Trust but verify or, better yet, verify, then trust.

Question 10
A recently admitted 56-year-old inpatient was discovered wrapping a towel around her neck. She denied suicidal intent; however, the treat­ment team viewed the incident as a suicide rehearsal. She was placed on one-to-one close observation.

Inpatient suicides frequently occur:
   a) shortly after admission
   b) during staff shift changes
   c) at meal times
   d) shortly after discharge
   e) all of the above

The best response option is E
Inpatient suicides also occur at increased frequency when psychiatric residents fin­ish their rotations and in understaffed psychiatric units.² Undue delay in the evaluation of a newly admitted acute, high-risk patient might allow the patient to commit suicide.

Most patient suicides occur shortly after hospital discharge (a few hours, days, or weeks later). Appleby et al³ found that the highest number of suicides occurred during the first week after discharge. Meehan et al⁴ found that suicide occurred most frequently during the first 2 weeks post-discharge; the highest number of suicides occurred on the first day after discharge.

Question 11
Ms. G, a 43-year-old, single woman in acute sui­cide crisis, is admitted to the psychiatric unit of a general hospital. She is diagnosed with bipolar I disorder, most recent episode depressed, and borderline personality disorder. She has had multiple psychiatric hospitalizations, all pre­cipitated by a suicide crisis. The average length of stay on the psychiatric unit is 6.3 days. After 7 days of intensive treatment, Ms. G is stabilized and suicide risk is reduced. The treatment team prepares for her discharge.

Ms. G’s suicide risk at discharge is most likely at:
   a) indeterminate risk
   b) low risk
   c) moderate risk
   d) chronic high risk
   e) acute high risk

 

The best response option is D
The length of stay in many acute care psy­chiatric facilities is <7 days. The goal of hospitalization is to stabilize the patient and discharge to appropriate community mental health resources. Discharge plan­ning begins at the time of admission.

Reducing Ms. G’s suicide risk to low or moderate is unlikely because of her diagnoses, frequent hospitalizations, and acute high risk for suicide on admission. After acute, high-risk suicidal patients are treated, many revert to chronic high risk for suicide.

Patients at chronic high risk for suicide often are treated as outpatients, except when an acute suicidal crisis requires hospi­talization.⁵ At discharge from the hospital, the goal is to return the patient to outpatient treatment.

A discharge note identifies the acute sui­cide risk factors that have abated and the chronic (long-term) suicide risk factors that remain. The discharge note also addresses a patient’s chronic vulnerability to suicide. For example, a patient can become acutely suicidal again, depending on a number of factors, including the nature and cause of the psychiatric illness, adequacy of future treat­ment, adherence to treatment recommenda­tions, and unforeseeable life vicissitudes.

Question 12
A 20-year-old college student is hospitalized after an overdose suicide attempt. Failing grades, panic attacks, and depression precipitated the suicide attempt. After 8 days of hos­pitalization, she is much improved and ready for discharge. She is assessed to be at low to moderate suicide risk. The treating psychiatrist and social worker convene a family meet­ing with both parents and an older brother. The family’s role after discharge is discussed.

All of the following options are helpful family roles except:
   a) provide constant 24-hour family supervision
   b) provide emotional support
   c) observe and report symptoms and behaviors of concern
   d) encourage adherence with treatment
   e) provide helpful feedback about the patient’s thoughts and behavior

The best response option is A
The family’s role is important, but it is not a substitute for constant safety management provided by trained mental health profes­sionals on an inpatient psychiatric unit.⁵ Early discharge of an inpatient by relying on family supervision can be precarious. Most inpatients are discharged at some level of suicide risk, given the short length of hos­pital stay. If an outpatient at risk of suicide requires constant 24-hour family supervi­sion, then psychiatric hospitalization is indicated.

Patients who are intent on killing them­selves can find ingenious ways to attempt or commit suicide. Asking family members to keep a constant watch often fails. Most family members will not follow the patient into the bathroom or be able to stay up all night to observe the patient. Moreover, fam­ily members find reasons to make exceptions to constant surveillance because of denial, fatigue, or the need to attend to other press­ing matters.


Question 13
During the initial evaluation of a patient, it is the psychiatrist’s practice to routinely inquire about current and past suicide ideation. An affirma­tive answer prompts a systematic suicide risk assessment. In the absence of current risk, if exploration of the patient’s history reveals chronic suicide risk factors, the psychiatrist con­ducts a systematic suicide risk assessment.

The chronic risk factor that has the highest association with suicide is:
   a) family history of mental illness or suicide
   b) childhood abuse
   c) history of a suicide attempt
   d) impulsivity or aggression
   e) prior psychiatric hospitalization

The best response option is C
A comprehensive suicide risk assessment may not be required at the initial outpatient evaluation in the absence of acute suicide risk factors. However, chronic suicide risk factors may be present.

The Standard Mortality Ratio (SMR) for prior suicide attempts by any method was 38.61.⁶ Suicide risk was highest in the 2 years after the first attempt. The SMR is a measure of the relative risk of suicide compared with the expected rate in the general population (SMR of 1).

Some chronic suicide risk factors are static: for example, a family history of psy­chiatric illness or earlier suicide attempt. Other chronic risk factors, usually a trait characteristic, can become acute: for exam­ple, impulsivity or aggression, or deliberate self-harm. The presence of chronic suicide risk factors should prompt a systematic sui­cide risk assessment. Evaluation of chronic suicide risk factors is an essential component of comprehensive assessment.5

Question 14
A psychiatrist is treating Dr. R, a 43-year-old physician, for anxiety and depression. The psychiatrist sees Dr. R twice a week for psy­chotherapy and medication management. A recent lawsuit filed against Dr. R has severely exacerbated her symptoms. She can sleep for only a few hours. Suicide ideation has emerged, frightening Dr. R and her family. The psychiatrist performs a systematic suicide risk assessment and determines that Dr. R is at acute high risk for suicide.

The psychiatrist recommends immediate hospitalization, but Dr. R adamantly refuses. The psychiatrist decides not to involuntarily hospitalize her because she does not meet the substantive criteria of the state involun­tary commitment statute (eg, overt suicidal behaviors). The psychiatrist chooses to con­tinue outpatient treatment.

 

Clinical interventions to reduce Dr. R’s suicide risk include:
   a) see her more often
   b) adjust medications
   c) obtain a consult
   d) refer her to an intensive outpatient program
   e) all of the above

The best response option is E
To hospitalize or not to hospitalize— that is the conundrum that psychiatrists often face with high-risk suicidal patients. The decision is more complicated when the need for hospitalization is clear but the patient refuses. The decisions that the psychiatrist makes at this point are crucial for treatment and risk management.⁵

If the patient disagrees with the psychiatrist’s recommendation to hospitalize, refusal should be addressed as a treatment issue. When the need for hospitalization is acute, a prolonged inquiry is not possible. In addition, the therapeutic alliance may become strained. This clinical situation tries a clinician’s professional mettle.

Consultation and referral are options to consider if time and the patient’s condition allows. A psychiatric clinician should never worry alone; sleepless nights benefit neither the psychiatrist nor the patient.

As Dr. R’s case shows, a psychiatrist might decide not to hospitalize a patient who is assessed to be at moderate or high risk of suicide. Protective factors may allow continuing outpatient treatment. A good therapeutic alliance may be present if the psychiatrist has worked with the patient for some time. Family support also may be available.

The clinician must determine if the patient’s suicide risk can be managed by more frequent visits and treatment adjust­ments. Also, supportive family members can help by providing observational data. Protective factors can be overwhelmed by a severe mental illness. In contrast, a patient assessed as being at moderate risk of suicide might need to be hospitalized when protec­tive factors are few or absent.

The psychiatrist may determine that a patient at high risk of suicide who refuses hospitalization does not meet criteria for involuntary hospitalization. For example, criteria might require that the patient must have made a suicide attempt within a speci­fied period of time. States have provisions in their commitment statutes granting immu­nity from liability if the clinician uses reason­able clinical judgment and acts in good faith when involuntarily hospitalizing a patient.⁷ 

Question 15
Mr. U, a 39-year-old, married engineer, is ready to be discharged from the inpatient unit. He was admitted 7 days earlier for acute alco­hol intoxication and suicidal threats. He has undergone successful detoxification. Mr. U has had 2 similar episodes within the past year.

The treatment team conducts a risk-benefit analysis for both discharge and continued hospi­talization. A consultation also is obtained.

The discharge decision will be most influenced by:
   a) presence of family support
   b) compliance with follow-up care
   c) availability of dual diagnosis programs
   d) systematic suicide risk assessment
   e) consultation


The best response option is D
All of the options in Question 15 concerning discharge planning of patients at risk for sui­cide are important. However, conducting a systematic suicide risk assessment to inform discharge planning is the most critical. Mr. U had 2 previous psychiatric admissions for alcohol abuse and suicidal ideation. He is a chronic suicide risk who becomes high risk when intoxicated.

Discharge planning begins at admission and is refined during the patient’s stay. Before a patient is discharged, a final post-discharge treatment and aftercare plan is necessary. After discharge, suicide risk increases as the intensity of treatment decreases.⁸

The patient’s willingness to cooperate with discharge and aftercare planning is critical in establishing contact with follow-up treat­ers. The treatment team should structure the follow-up plan to encourage compliance. For example, psychotic patients at risk of suicide who have a history of stopping medications after discharge can be given a long-acting IM antipsychotic that will last until they reach aftercare. Patients with comorbid drug and alcohol abuse disorders are referred to agen­cies equipped to manage dual-diagnosis patients.

Psychiatrists’ ability to ensure follow-up treatment is limited, a fact that must be acknowledged by the psychiatric and legal communities. Beyond patient stabilization, a clinician’s options to bring about posi­tive changes can be limited or nonexistent. Also, the patient’s failure to adhere to post-discharge plans and treatment often leads to rehospitalization, hopelessness, and greater suicide risk.

Psychiatric patients at moderate or moderate-to-high risk for suicide increas­ingly are treated in outpatient settings. It is the responsibility of the clinician and the treatment team to competently hand off the patient to appropriate outpatient aftercare. With the patient’s permission, the psychia­trist or social worker should call the follow-up agency or therapist before discharge to provide information about the patient’s diagnosis, treatment, and hospital course.

Last, follow-up appointments should be made as close to the time of discharge as possible. Suicide often occurs on the first day after discharge.³

 

Bottom Line
Fully commit time and effort to the ongoing assessment, treatment, and management of patients at suicide risk. Suicide risk assessment is a process, not an event. Conduct a suicide risk assessment at important clinical junctures (eg, initial evaluation, discharge, changing observation levels). Contemporaneously, document suicide risk assessments. This self-assessment helps clinicians gauge their strengths and identify skills that need further development.

Disclosure
Dr. Simon reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Simon is the co-editor of The American Psychiatry Publishing textbook of Suicide Assessment and Management, 2nd edition, from which this article is adapted, by permission of the publisher, American Psychiatry Publishing, Inc. ©2012.

mmmm

When I last wrote about the Affordable Care Act (ACA), in May 2014, I focused on the contraception issue. Since then, the US Supreme Court ruled, in Burwell v. Hobby Lobby, that closely held, for-profit companies with religious objections to covering birth control can opt out of the requirement to provide contraceptive coverage to their employees.

In this article, I explore that decision and what it means for women’s health. I also present data on the uninsured rate in the United States, which has dropped significantly since enactment of the ACA, and I discuss one increasingly common barrier to access to care—the use of narrow networks by insurers.

A corporation now can hold a religious belief
The Supreme Court’s majority 5-4 ruling recognized, for the first time, that a for-profit corporation can hold a religious belief, but the Court limited this claim to closely held corporations. The Court also decided that the ACA placed a substantial burden on the corporations’ religious beliefs and concluded that there are less burdensome ways to accomplish the law’s intent, rendering the contraceptive coverage provision in the ACA in violation of the Religious Freedom Restoration Act (RFRA). The Court limited its ruling to the contraceptive coverage requirement, essentially turning the requirement into an option for many employers.

What is a closely held corporation?
In general, according to the Pew Research Center, a closely held corporation is a private company (not publicly traded) with a limited number of shareholders. The Internal Revenue Service (IRS), an important source, defines a closely held corporation as one in which more than half of the stock is owned (directly or indirectly) by five or fewer individuals at any time in the second half of the year.

“S” corporations are also considered closely held. These are corporations with 100 or fewer shareholders, with all members of the same family counted as one shareholder. “S” corporations don’t pay income tax; their shareholders pay tax on their personal returns, based on the corporations’ profits and losses.

Hobby Lobby is organized as an “S” corporation. According to the IRS, in 2011, there were 4,158,572 “S” corporations, 99.4% of them with 10 or fewer shareholders.¹

The US Census Bureau estimates that, in 2012, about 2.9 million “S” corporations employed more than 29 million people. Many closely held corporations are quite large.² According to the Pew Research Center, family-owned Cargill employs 140,000 people and had $136.7 billion in revenue in fiscal 2013. Hobby Lobby has estimated revenues of $3.3 billion and 23,000 employees.²

What’s next?
ACOG helped secure coverage of contraceptives in the ACA and is working with the US Congress and our women’s health partners to restore this important care. Days after the Supreme Court decision, Senator Patty Murray (D-WA) introduced the Protect Women’s Health from Corporate Interference Act, S. 2578, with 46 cosponsors as of this writing. ACOG fully supports this bill, also known as the “Not My Boss’ Business Bill,” which would reestablish the contraceptive coverage mandate as well as other care required by federal law. This bill still maintains the exemption from contraceptive coverage for houses of worship and the accommodation for religious nonprofits.

In introducing her bill, Senator Murray pointed out that “the contraceptive coverage requirement has already made a tremendous difference in women’s lives—24 million more prescriptions for oral contraceptives were filled with no copay in 2013 than in 2012, and women have saved $483 million in out-of-pocket costs for oral contraceptives.”³

Uninsured rate is declining
The Commonwealth Fund shows that, from July–September 2013 to April–June 2014, the nation’s uninsured rate fell from 20% to 15%, resulting in 9.5 million fewer uninsured adults.⁴ The biggest drop occurred among young adults, with the uninsured rate falling from 28% to 18%, and in states that adopted the Medicaid expansion, where uninsured rates fell from 28% to 17%.⁴

 

States that didn’t expand their Medicaid program didn’t show any noticeable change, with the uninsured rate declining only two points, from 38% to 36%.⁴

Coverage resulted in access to care for the majority of the newly covered. Sixty percent of people with new coverage visited a provider or hospital or paid for a prescription. Sixty-two percent of these individuals said they wouldn’t have been able to access this care before getting this coverage. Eighty-one percent of people with new coverage said they were better off now than before.⁴

ACA works better in some states than others
The Kaiser Family Foundation looked at four successful states—Colorado, Connecticut, Kentucky, and Washington state—to see what lessons can be learned. Important commonalities include the fact that the states run their own marketplace, adopted the Medi-caid expansion, and conducted extensive outreach and public education, including engaging providers in patient outreach and enrollment.⁵

Other tools of success were developing good marketing and branding, providing consumer-friendly assistance, and attention to systems and operations.⁵

State	Contraceptive equity law?	Employer/insurer exemption to equity law?	Religious freedom law?
Alabama			✔
Alaska
Arizona	✔	✔	✔
Arkansas	✔	✔
California	✔	✔
Colorado	✔
Connecticut	✔	✔	✔
Delaware	✔	✔
Florida			✔
Georgia	✔
Hawaii	✔	✔
Idaho			✔
Illinois	✔	✔	✔
Indiana
Iowa	✔
Kansas
Kentucky			✔
Louisiana			✔
Maine	✔	✔
Maryland	✔	✔
Massachusetts	✔	✔
Michigan	✔	✔
Minnesota
Mississippi			✔
Missouri	✔	✔	✔
Montana	✔
Nebraska
Nevada	✔	✔
New Hampshire	✔
New Jersey	✔	✔
New Mexico	✔	✔	✔
New York	✔	✔
North Carolina	✔	✔
North Dakota
Ohio
Oklahoma			✔
Oregon	✔	✔
Pennsylvania			✔
Rhode Island	✔	✔	✔
South Carolina			✔
South Dakota
Tennessee			✔
Texas			✔
Utah
Vermont	✔
Virginia			✔
Washington	✔
West Virginia	✔	✔
Wisconsin	✔
Wyoming
TOTAL	28	20	18

Narrow networks limit access to care
Huge concerns abound regarding implementation and real-life experiences related to the ACA. A number of them—high deductibles, low payment rates, limited access to physicians, long drive and wait times—can be related to “narrow networks.” Insurers exclude certain providers and offer all providers lower payment rates (which leads some physicians to drop out of the plan); they also create tiers (charging consumers lower copays and deductibles for using inner-tier preferred providers and high out-of-pocket costs for using other providers, even though they may be in the network).

Narrow networks work for insurers as an effective tool for lowering provider payment rates to keep premiums low and gain market share. The narrower the network, the lower are physician payments and premiums.

The ACA promises expanded access to high-quality, affordable health care for millions of Americans—a promise being compromised in many areas of the country through narrow networks. In these instances, insurers offering new plans in a health-care marketplace limit patient access to the numbers, types, and locations of physicians and hospitals covered under certain plans. Insurers typically offer patients low premiums, offer selected providers a high volume of patients at low payment levels, and exclude other providers whom the insurer deems to be high-cost.

Narrow networks aren’t new
As with so many elements of the ACA, narrow networks aren’t a new phenomenon. Many of us remember the public relations price that HMOs paid in the 1980s and 1990s for exceedingly limiting patients’ access to care while charging low premiums. The consumer outcry led the National Association of Insurance Commissioners to urge states to require managed-care plans to maintain adequate networks, the approach adopted by the federal government in the ACA.6

 

The pendulum swung in the next decade to broader networks in which consumers had much greater access, but premiums increased by an average of 11% per year.⁶ Employers then pushed insurers to reduce premium costs, leading back to narrow ­networks in the years just before the ACA. Narrow network plans accounted for 23% of all employer-sponsored plans in 2012, up from 15% in 2007.⁶

Increasing consolidation contributes to narrow networks
The trend toward narrower networks is also linked to increasing consolidation in health care. As health systems grow and individual or small group practices disappear, insurers rely on being able to credibly threaten to exclude systems and big groups from their networks as leverage in payment negotiations. By restricting the choice of providers in a plan, the insurer can promise more customers for the doctors and hospitals that are included, and negotiate lower payments to those providers.

The downside for physicians is clear:

• low payment rates
• exclusion from networks and coverage
• inability to refer patients to providers the physician determines to be best for that patient’s needs.
• The downside for patients:
• If they have to go out of network to get needed care, they may end up paying high out-of-pocket costs
• If they delay or forego care, their health may suffer significantly.

The insurance industry’s position is that patients have choices. Plans with access to more hospitals and specialists are available but usually at a higher price.

Narrow networks are one way to achieve low premiums
In the months leading up to ACA enactment, insurers got to work developing plans designed to be sold on the exchanges that would attract consumers through low-cost premiums and still maximize profits, especially now that insurers, under the ACA, are barred from excluding sick enrollees or increasing premiums for women, in addition to other important protections.

In previous articles, we’ve explored these landmark protections. Insurers in the individual market used to be able to keep ­premiums relatively low, and profits up, through use of preexisting coverage exclusions, benefit exclusions including noncoverage for maternity care or prescription drugs, and high cost sharing. Not anymore.

Since enactment of the ACA, narrow networks seem to be the preferred, and most effective, payment negotiation tool of many insurers offering plans through the exchanges, reflecting the trend we’re already seeing in the private health insurance marketplace.

NPR spotlights the difficulty of finding a specialist
The consumer and provider problems of narrow networks have been gaining attention in the media. In July, the National Public Radio (NPR) Web site carried an article entitled, “Patients with low-cost insurance struggle to find specialists,” with a key subtitle: “So you found an exchange plan. But can you find a provider?”⁷

In the NPR article, author Carrie ­Feibel reported on the situation in a majority-­immigrant area of southwest Houston.

There, many patients at the local clinic have health insurance coverage for the first time, an important step toward healthier lives for themselves and their families. But many people in need of a specialist are learning that their insurance card doesn’t guarantee them access to a needed surgeon or hospital. They’ve purchased a narrow-network insurance plan, with a low premium but few specialists who accept that insurance.⁷

The two largest hospital chains in Houston—Houston Methodist and Memorial Hermann—as well as Houston’s MD Anderson Cancer Center, don’t participate in the Blue Cross Blue Shield HMO Silver plan, a plan popular with low-income consumers because of its low premium.⁷

Will the government take action?
The ACA actually guards against overly narrow networks and established the first national standard for network adequacy—a standard that needs fuller development, for sure. Plans sold on the exchanges are required to establish networks that include, among other providers, essential community providers, who typically care for mostly low-income and medically underserved populations. Networks also must include sufficient numbers and types of providers, including “providers that specialize in mental health and substance abuse services, to assure that all services will be accessible without unreasonable delay.”⁸

Insurers also must provide people who are considering purchasing their products with an accurate directory—both online and a hard copy—identifying providers not accepting new patients in the network. And plans are prohibited from charging out-of-network cost-sharing for emergency services.

Much of the oversight and many of the details—how much is adequate? what is unreasonable?—are left to the states, many of which have years of experience grappling with the downsides and delicate balance of networks.

The Urban Institute points out that Vermont and Delaware set standards for maximum geographic distance and drive times for primary care services. In California, plans must make it easy for consumers to reach urban providers on public transportation.⁶

 

Professional societies are taking note
Today, the misuse of narrow networks by exchange plans also has gotten the attention of the American Medical Association, ACOG, and many other national medical specialty societies, in addition to the states and federal government.

The trick, many health-care policy experts agree, is to find the right balance. How broad can the network be before premiums soar? Most agree that consumers must be able to choose between plans with confidence, without any cost or access surprises, meaning much better transparency. And many agree that provider quality, in addition to cost, has to find its way into the equation.

This year, the Center for Consumer Information and Insurance Oversight, a part of the federal Department of Health and Human Services created by the ACA to investigate these kinds of issues, is investigating access to hospital systems, mental health services, oncology, and primary care providers and is developing time, distance, and other standards that insurers will have to adhere to.

Employer groups oppose strong standards or limits on narrow networks. Recently, representatives of the US Chamber of Commerce, the ­National ­Retail Federation, and others warned ­Congress to stay out of this fight. They understand that more generous networks mean higher premiums. These employer representative groups prefer to strengthen consumer protections like directories and keep low the cost of health insurance that they provide for their employees. 

Acknowledgment
The author acknowledges the work and expertise of ACOG's state government affairs team for the state analysis—Kathryn Moore, Director, and Kate Vlach, Senior Manager—as well as advocacy partners.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

mmmm

When I last wrote about the Affordable Care Act (ACA), in May 2014, I focused on the contraception issue. Since then, the US Supreme Court ruled, in Burwell v. Hobby Lobby, that closely held, for-profit companies with religious objections to covering birth control can opt out of the requirement to provide contraceptive coverage to their employees.

In this article, I explore that decision and what it means for women’s health. I also present data on the uninsured rate in the United States, which has dropped significantly since enactment of the ACA, and I discuss one increasingly common barrier to access to care—the use of narrow networks by insurers.

A corporation now can hold a religious belief
The Supreme Court’s majority 5-4 ruling recognized, for the first time, that a for-profit corporation can hold a religious belief, but the Court limited this claim to closely held corporations. The Court also decided that the ACA placed a substantial burden on the corporations’ religious beliefs and concluded that there are less burdensome ways to accomplish the law’s intent, rendering the contraceptive coverage provision in the ACA in violation of the Religious Freedom Restoration Act (RFRA). The Court limited its ruling to the contraceptive coverage requirement, essentially turning the requirement into an option for many employers.

What is a closely held corporation?
In general, according to the Pew Research Center, a closely held corporation is a private company (not publicly traded) with a limited number of shareholders. The Internal Revenue Service (IRS), an important source, defines a closely held corporation as one in which more than half of the stock is owned (directly or indirectly) by five or fewer individuals at any time in the second half of the year.

“S” corporations are also considered closely held. These are corporations with 100 or fewer shareholders, with all members of the same family counted as one shareholder. “S” corporations don’t pay income tax; their shareholders pay tax on their personal returns, based on the corporations’ profits and losses.

Hobby Lobby is organized as an “S” corporation. According to the IRS, in 2011, there were 4,158,572 “S” corporations, 99.4% of them with 10 or fewer shareholders.¹

The US Census Bureau estimates that, in 2012, about 2.9 million “S” corporations employed more than 29 million people. Many closely held corporations are quite large.² According to the Pew Research Center, family-owned Cargill employs 140,000 people and had $136.7 billion in revenue in fiscal 2013. Hobby Lobby has estimated revenues of $3.3 billion and 23,000 employees.²

What’s next?
ACOG helped secure coverage of contraceptives in the ACA and is working with the US Congress and our women’s health partners to restore this important care. Days after the Supreme Court decision, Senator Patty Murray (D-WA) introduced the Protect Women’s Health from Corporate Interference Act, S. 2578, with 46 cosponsors as of this writing. ACOG fully supports this bill, also known as the “Not My Boss’ Business Bill,” which would reestablish the contraceptive coverage mandate as well as other care required by federal law. This bill still maintains the exemption from contraceptive coverage for houses of worship and the accommodation for religious nonprofits.

In introducing her bill, Senator Murray pointed out that “the contraceptive coverage requirement has already made a tremendous difference in women’s lives—24 million more prescriptions for oral contraceptives were filled with no copay in 2013 than in 2012, and women have saved $483 million in out-of-pocket costs for oral contraceptives.”³

Uninsured rate is declining
The Commonwealth Fund shows that, from July–September 2013 to April–June 2014, the nation’s uninsured rate fell from 20% to 15%, resulting in 9.5 million fewer uninsured adults.⁴ The biggest drop occurred among young adults, with the uninsured rate falling from 28% to 18%, and in states that adopted the Medicaid expansion, where uninsured rates fell from 28% to 17%.⁴

 

States that didn’t expand their Medicaid program didn’t show any noticeable change, with the uninsured rate declining only two points, from 38% to 36%.⁴

Coverage resulted in access to care for the majority of the newly covered. Sixty percent of people with new coverage visited a provider or hospital or paid for a prescription. Sixty-two percent of these individuals said they wouldn’t have been able to access this care before getting this coverage. Eighty-one percent of people with new coverage said they were better off now than before.⁴

ACA works better in some states than others
The Kaiser Family Foundation looked at four successful states—Colorado, Connecticut, Kentucky, and Washington state—to see what lessons can be learned. Important commonalities include the fact that the states run their own marketplace, adopted the Medi-caid expansion, and conducted extensive outreach and public education, including engaging providers in patient outreach and enrollment.⁵

Other tools of success were developing good marketing and branding, providing consumer-friendly assistance, and attention to systems and operations.⁵

State	Contraceptive equity law?	Employer/insurer exemption to equity law?	Religious freedom law?
Alabama			✔
Alaska
Arizona	✔	✔	✔
Arkansas	✔	✔
California	✔	✔
Colorado	✔
Connecticut	✔	✔	✔
Delaware	✔	✔
Florida			✔
Georgia	✔
Hawaii	✔	✔
Idaho			✔
Illinois	✔	✔	✔
Indiana
Iowa	✔
Kansas
Kentucky			✔
Louisiana			✔
Maine	✔	✔
Maryland	✔	✔
Massachusetts	✔	✔
Michigan	✔	✔
Minnesota
Mississippi			✔
Missouri	✔	✔	✔
Montana	✔
Nebraska
Nevada	✔	✔
New Hampshire	✔
New Jersey	✔	✔
New Mexico	✔	✔	✔
New York	✔	✔
North Carolina	✔	✔
North Dakota
Ohio
Oklahoma			✔
Oregon	✔	✔
Pennsylvania			✔
Rhode Island	✔	✔	✔
South Carolina			✔
South Dakota
Tennessee			✔
Texas			✔
Utah
Vermont	✔
Virginia			✔
Washington	✔
West Virginia	✔	✔
Wisconsin	✔
Wyoming
TOTAL	28	20	18

Narrow networks limit access to care
Huge concerns abound regarding implementation and real-life experiences related to the ACA. A number of them—high deductibles, low payment rates, limited access to physicians, long drive and wait times—can be related to “narrow networks.” Insurers exclude certain providers and offer all providers lower payment rates (which leads some physicians to drop out of the plan); they also create tiers (charging consumers lower copays and deductibles for using inner-tier preferred providers and high out-of-pocket costs for using other providers, even though they may be in the network).

Narrow networks work for insurers as an effective tool for lowering provider payment rates to keep premiums low and gain market share. The narrower the network, the lower are physician payments and premiums.

The ACA promises expanded access to high-quality, affordable health care for millions of Americans—a promise being compromised in many areas of the country through narrow networks. In these instances, insurers offering new plans in a health-care marketplace limit patient access to the numbers, types, and locations of physicians and hospitals covered under certain plans. Insurers typically offer patients low premiums, offer selected providers a high volume of patients at low payment levels, and exclude other providers whom the insurer deems to be high-cost.

Narrow networks aren’t new
As with so many elements of the ACA, narrow networks aren’t a new phenomenon. Many of us remember the public relations price that HMOs paid in the 1980s and 1990s for exceedingly limiting patients’ access to care while charging low premiums. The consumer outcry led the National Association of Insurance Commissioners to urge states to require managed-care plans to maintain adequate networks, the approach adopted by the federal government in the ACA.6

 

The pendulum swung in the next decade to broader networks in which consumers had much greater access, but premiums increased by an average of 11% per year.⁶ Employers then pushed insurers to reduce premium costs, leading back to narrow ­networks in the years just before the ACA. Narrow network plans accounted for 23% of all employer-sponsored plans in 2012, up from 15% in 2007.⁶

Increasing consolidation contributes to narrow networks
The trend toward narrower networks is also linked to increasing consolidation in health care. As health systems grow and individual or small group practices disappear, insurers rely on being able to credibly threaten to exclude systems and big groups from their networks as leverage in payment negotiations. By restricting the choice of providers in a plan, the insurer can promise more customers for the doctors and hospitals that are included, and negotiate lower payments to those providers.

The downside for physicians is clear:

• low payment rates
• exclusion from networks and coverage
• inability to refer patients to providers the physician determines to be best for that patient’s needs.
• The downside for patients:
• If they have to go out of network to get needed care, they may end up paying high out-of-pocket costs
• If they delay or forego care, their health may suffer significantly.

The insurance industry’s position is that patients have choices. Plans with access to more hospitals and specialists are available but usually at a higher price.

Narrow networks are one way to achieve low premiums
In the months leading up to ACA enactment, insurers got to work developing plans designed to be sold on the exchanges that would attract consumers through low-cost premiums and still maximize profits, especially now that insurers, under the ACA, are barred from excluding sick enrollees or increasing premiums for women, in addition to other important protections.

In previous articles, we’ve explored these landmark protections. Insurers in the individual market used to be able to keep ­premiums relatively low, and profits up, through use of preexisting coverage exclusions, benefit exclusions including noncoverage for maternity care or prescription drugs, and high cost sharing. Not anymore.

Since enactment of the ACA, narrow networks seem to be the preferred, and most effective, payment negotiation tool of many insurers offering plans through the exchanges, reflecting the trend we’re already seeing in the private health insurance marketplace.

NPR spotlights the difficulty of finding a specialist
The consumer and provider problems of narrow networks have been gaining attention in the media. In July, the National Public Radio (NPR) Web site carried an article entitled, “Patients with low-cost insurance struggle to find specialists,” with a key subtitle: “So you found an exchange plan. But can you find a provider?”⁷

In the NPR article, author Carrie ­Feibel reported on the situation in a majority-­immigrant area of southwest Houston.

There, many patients at the local clinic have health insurance coverage for the first time, an important step toward healthier lives for themselves and their families. But many people in need of a specialist are learning that their insurance card doesn’t guarantee them access to a needed surgeon or hospital. They’ve purchased a narrow-network insurance plan, with a low premium but few specialists who accept that insurance.⁷

The two largest hospital chains in Houston—Houston Methodist and Memorial Hermann—as well as Houston’s MD Anderson Cancer Center, don’t participate in the Blue Cross Blue Shield HMO Silver plan, a plan popular with low-income consumers because of its low premium.⁷

Will the government take action?
The ACA actually guards against overly narrow networks and established the first national standard for network adequacy—a standard that needs fuller development, for sure. Plans sold on the exchanges are required to establish networks that include, among other providers, essential community providers, who typically care for mostly low-income and medically underserved populations. Networks also must include sufficient numbers and types of providers, including “providers that specialize in mental health and substance abuse services, to assure that all services will be accessible without unreasonable delay.”⁸

Insurers also must provide people who are considering purchasing their products with an accurate directory—both online and a hard copy—identifying providers not accepting new patients in the network. And plans are prohibited from charging out-of-network cost-sharing for emergency services.

Much of the oversight and many of the details—how much is adequate? what is unreasonable?—are left to the states, many of which have years of experience grappling with the downsides and delicate balance of networks.

The Urban Institute points out that Vermont and Delaware set standards for maximum geographic distance and drive times for primary care services. In California, plans must make it easy for consumers to reach urban providers on public transportation.⁶

 

Professional societies are taking note
Today, the misuse of narrow networks by exchange plans also has gotten the attention of the American Medical Association, ACOG, and many other national medical specialty societies, in addition to the states and federal government.

The trick, many health-care policy experts agree, is to find the right balance. How broad can the network be before premiums soar? Most agree that consumers must be able to choose between plans with confidence, without any cost or access surprises, meaning much better transparency. And many agree that provider quality, in addition to cost, has to find its way into the equation.

This year, the Center for Consumer Information and Insurance Oversight, a part of the federal Department of Health and Human Services created by the ACA to investigate these kinds of issues, is investigating access to hospital systems, mental health services, oncology, and primary care providers and is developing time, distance, and other standards that insurers will have to adhere to.

Employer groups oppose strong standards or limits on narrow networks. Recently, representatives of the US Chamber of Commerce, the ­National ­Retail Federation, and others warned ­Congress to stay out of this fight. They understand that more generous networks mean higher premiums. These employer representative groups prefer to strengthen consumer protections like directories and keep low the cost of health insurance that they provide for their employees. 

Acknowledgment
The author acknowledges the work and expertise of ACOG's state government affairs team for the state analysis—Kathryn Moore, Director, and Kate Vlach, Senior Manager—as well as advocacy partners.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

mmmm

When I last wrote about the Affordable Care Act (ACA), in May 2014, I focused on the contraception issue. Since then, the US Supreme Court ruled, in Burwell v. Hobby Lobby, that closely held, for-profit companies with religious objections to covering birth control can opt out of the requirement to provide contraceptive coverage to their employees.

In this article, I explore that decision and what it means for women’s health. I also present data on the uninsured rate in the United States, which has dropped significantly since enactment of the ACA, and I discuss one increasingly common barrier to access to care—the use of narrow networks by insurers.

A corporation now can hold a religious belief
The Supreme Court’s majority 5-4 ruling recognized, for the first time, that a for-profit corporation can hold a religious belief, but the Court limited this claim to closely held corporations. The Court also decided that the ACA placed a substantial burden on the corporations’ religious beliefs and concluded that there are less burdensome ways to accomplish the law’s intent, rendering the contraceptive coverage provision in the ACA in violation of the Religious Freedom Restoration Act (RFRA). The Court limited its ruling to the contraceptive coverage requirement, essentially turning the requirement into an option for many employers.

What is a closely held corporation?
In general, according to the Pew Research Center, a closely held corporation is a private company (not publicly traded) with a limited number of shareholders. The Internal Revenue Service (IRS), an important source, defines a closely held corporation as one in which more than half of the stock is owned (directly or indirectly) by five or fewer individuals at any time in the second half of the year.

“S” corporations are also considered closely held. These are corporations with 100 or fewer shareholders, with all members of the same family counted as one shareholder. “S” corporations don’t pay income tax; their shareholders pay tax on their personal returns, based on the corporations’ profits and losses.

Hobby Lobby is organized as an “S” corporation. According to the IRS, in 2011, there were 4,158,572 “S” corporations, 99.4% of them with 10 or fewer shareholders.¹

The US Census Bureau estimates that, in 2012, about 2.9 million “S” corporations employed more than 29 million people. Many closely held corporations are quite large.² According to the Pew Research Center, family-owned Cargill employs 140,000 people and had $136.7 billion in revenue in fiscal 2013. Hobby Lobby has estimated revenues of $3.3 billion and 23,000 employees.²

What’s next?
ACOG helped secure coverage of contraceptives in the ACA and is working with the US Congress and our women’s health partners to restore this important care. Days after the Supreme Court decision, Senator Patty Murray (D-WA) introduced the Protect Women’s Health from Corporate Interference Act, S. 2578, with 46 cosponsors as of this writing. ACOG fully supports this bill, also known as the “Not My Boss’ Business Bill,” which would reestablish the contraceptive coverage mandate as well as other care required by federal law. This bill still maintains the exemption from contraceptive coverage for houses of worship and the accommodation for religious nonprofits.

In introducing her bill, Senator Murray pointed out that “the contraceptive coverage requirement has already made a tremendous difference in women’s lives—24 million more prescriptions for oral contraceptives were filled with no copay in 2013 than in 2012, and women have saved $483 million in out-of-pocket costs for oral contraceptives.”³

Uninsured rate is declining
The Commonwealth Fund shows that, from July–September 2013 to April–June 2014, the nation’s uninsured rate fell from 20% to 15%, resulting in 9.5 million fewer uninsured adults.⁴ The biggest drop occurred among young adults, with the uninsured rate falling from 28% to 18%, and in states that adopted the Medicaid expansion, where uninsured rates fell from 28% to 17%.⁴

 

States that didn’t expand their Medicaid program didn’t show any noticeable change, with the uninsured rate declining only two points, from 38% to 36%.⁴

Coverage resulted in access to care for the majority of the newly covered. Sixty percent of people with new coverage visited a provider or hospital or paid for a prescription. Sixty-two percent of these individuals said they wouldn’t have been able to access this care before getting this coverage. Eighty-one percent of people with new coverage said they were better off now than before.⁴

ACA works better in some states than others
The Kaiser Family Foundation looked at four successful states—Colorado, Connecticut, Kentucky, and Washington state—to see what lessons can be learned. Important commonalities include the fact that the states run their own marketplace, adopted the Medi-caid expansion, and conducted extensive outreach and public education, including engaging providers in patient outreach and enrollment.⁵

Other tools of success were developing good marketing and branding, providing consumer-friendly assistance, and attention to systems and operations.⁵

State	Contraceptive equity law?	Employer/insurer exemption to equity law?	Religious freedom law?
Alabama			✔
Alaska
Arizona	✔	✔	✔
Arkansas	✔	✔
California	✔	✔
Colorado	✔
Connecticut	✔	✔	✔
Delaware	✔	✔
Florida			✔
Georgia	✔
Hawaii	✔	✔
Idaho			✔
Illinois	✔	✔	✔
Indiana
Iowa	✔
Kansas
Kentucky			✔
Louisiana			✔
Maine	✔	✔
Maryland	✔	✔
Massachusetts	✔	✔
Michigan	✔	✔
Minnesota
Mississippi			✔
Missouri	✔	✔	✔
Montana	✔
Nebraska
Nevada	✔	✔
New Hampshire	✔
New Jersey	✔	✔
New Mexico	✔	✔	✔
New York	✔	✔
North Carolina	✔	✔
North Dakota
Ohio
Oklahoma			✔
Oregon	✔	✔
Pennsylvania			✔
Rhode Island	✔	✔	✔
South Carolina			✔
South Dakota
Tennessee			✔
Texas			✔
Utah
Vermont	✔
Virginia			✔
Washington	✔
West Virginia	✔	✔
Wisconsin	✔
Wyoming
TOTAL	28	20	18

Narrow networks limit access to care
Huge concerns abound regarding implementation and real-life experiences related to the ACA. A number of them—high deductibles, low payment rates, limited access to physicians, long drive and wait times—can be related to “narrow networks.” Insurers exclude certain providers and offer all providers lower payment rates (which leads some physicians to drop out of the plan); they also create tiers (charging consumers lower copays and deductibles for using inner-tier preferred providers and high out-of-pocket costs for using other providers, even though they may be in the network).

Narrow networks work for insurers as an effective tool for lowering provider payment rates to keep premiums low and gain market share. The narrower the network, the lower are physician payments and premiums.

The ACA promises expanded access to high-quality, affordable health care for millions of Americans—a promise being compromised in many areas of the country through narrow networks. In these instances, insurers offering new plans in a health-care marketplace limit patient access to the numbers, types, and locations of physicians and hospitals covered under certain plans. Insurers typically offer patients low premiums, offer selected providers a high volume of patients at low payment levels, and exclude other providers whom the insurer deems to be high-cost.

Narrow networks aren’t new
As with so many elements of the ACA, narrow networks aren’t a new phenomenon. Many of us remember the public relations price that HMOs paid in the 1980s and 1990s for exceedingly limiting patients’ access to care while charging low premiums. The consumer outcry led the National Association of Insurance Commissioners to urge states to require managed-care plans to maintain adequate networks, the approach adopted by the federal government in the ACA.6

 

The pendulum swung in the next decade to broader networks in which consumers had much greater access, but premiums increased by an average of 11% per year.⁶ Employers then pushed insurers to reduce premium costs, leading back to narrow ­networks in the years just before the ACA. Narrow network plans accounted for 23% of all employer-sponsored plans in 2012, up from 15% in 2007.⁶

Increasing consolidation contributes to narrow networks
The trend toward narrower networks is also linked to increasing consolidation in health care. As health systems grow and individual or small group practices disappear, insurers rely on being able to credibly threaten to exclude systems and big groups from their networks as leverage in payment negotiations. By restricting the choice of providers in a plan, the insurer can promise more customers for the doctors and hospitals that are included, and negotiate lower payments to those providers.

The downside for physicians is clear:

• low payment rates
• exclusion from networks and coverage
• inability to refer patients to providers the physician determines to be best for that patient’s needs.
• The downside for patients:
• If they have to go out of network to get needed care, they may end up paying high out-of-pocket costs
• If they delay or forego care, their health may suffer significantly.

The insurance industry’s position is that patients have choices. Plans with access to more hospitals and specialists are available but usually at a higher price.

Narrow networks are one way to achieve low premiums
In the months leading up to ACA enactment, insurers got to work developing plans designed to be sold on the exchanges that would attract consumers through low-cost premiums and still maximize profits, especially now that insurers, under the ACA, are barred from excluding sick enrollees or increasing premiums for women, in addition to other important protections.

In previous articles, we’ve explored these landmark protections. Insurers in the individual market used to be able to keep ­premiums relatively low, and profits up, through use of preexisting coverage exclusions, benefit exclusions including noncoverage for maternity care or prescription drugs, and high cost sharing. Not anymore.

Since enactment of the ACA, narrow networks seem to be the preferred, and most effective, payment negotiation tool of many insurers offering plans through the exchanges, reflecting the trend we’re already seeing in the private health insurance marketplace.

NPR spotlights the difficulty of finding a specialist
The consumer and provider problems of narrow networks have been gaining attention in the media. In July, the National Public Radio (NPR) Web site carried an article entitled, “Patients with low-cost insurance struggle to find specialists,” with a key subtitle: “So you found an exchange plan. But can you find a provider?”⁷

In the NPR article, author Carrie ­Feibel reported on the situation in a majority-­immigrant area of southwest Houston.

There, many patients at the local clinic have health insurance coverage for the first time, an important step toward healthier lives for themselves and their families. But many people in need of a specialist are learning that their insurance card doesn’t guarantee them access to a needed surgeon or hospital. They’ve purchased a narrow-network insurance plan, with a low premium but few specialists who accept that insurance.⁷

The two largest hospital chains in Houston—Houston Methodist and Memorial Hermann—as well as Houston’s MD Anderson Cancer Center, don’t participate in the Blue Cross Blue Shield HMO Silver plan, a plan popular with low-income consumers because of its low premium.⁷

Will the government take action?
The ACA actually guards against overly narrow networks and established the first national standard for network adequacy—a standard that needs fuller development, for sure. Plans sold on the exchanges are required to establish networks that include, among other providers, essential community providers, who typically care for mostly low-income and medically underserved populations. Networks also must include sufficient numbers and types of providers, including “providers that specialize in mental health and substance abuse services, to assure that all services will be accessible without unreasonable delay.”⁸

Insurers also must provide people who are considering purchasing their products with an accurate directory—both online and a hard copy—identifying providers not accepting new patients in the network. And plans are prohibited from charging out-of-network cost-sharing for emergency services.

Much of the oversight and many of the details—how much is adequate? what is unreasonable?—are left to the states, many of which have years of experience grappling with the downsides and delicate balance of networks.

The Urban Institute points out that Vermont and Delaware set standards for maximum geographic distance and drive times for primary care services. In California, plans must make it easy for consumers to reach urban providers on public transportation.⁶

 

Professional societies are taking note
Today, the misuse of narrow networks by exchange plans also has gotten the attention of the American Medical Association, ACOG, and many other national medical specialty societies, in addition to the states and federal government.

The trick, many health-care policy experts agree, is to find the right balance. How broad can the network be before premiums soar? Most agree that consumers must be able to choose between plans with confidence, without any cost or access surprises, meaning much better transparency. And many agree that provider quality, in addition to cost, has to find its way into the equation.

This year, the Center for Consumer Information and Insurance Oversight, a part of the federal Department of Health and Human Services created by the ACA to investigate these kinds of issues, is investigating access to hospital systems, mental health services, oncology, and primary care providers and is developing time, distance, and other standards that insurers will have to adhere to.

Employer groups oppose strong standards or limits on narrow networks. Recently, representatives of the US Chamber of Commerce, the ­National ­Retail Federation, and others warned ­Congress to stay out of this fight. They understand that more generous networks mean higher premiums. These employer representative groups prefer to strengthen consumer protections like directories and keep low the cost of health insurance that they provide for their employees. 

Acknowledgment
The author acknowledges the work and expertise of ACOG's state government affairs team for the state analysis—Kathryn Moore, Director, and Kate Vlach, Senior Manager—as well as advocacy partners.

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