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Dealing with insurance plans can be challenging, especially when you are already stressed and worried about mental health issues you or a loved one are experiencing. For this reason, it is best to understand your benefits before you need to use them, if at all possible. The following are steps you can take to make sure you understand your benefits so that you can do whatever is within your control to have your treatment covered.

Reviewing Your Insurance Policy
The first thing to find out is what mental health benefits your insurance policy offers. Review your insurance policy so that you are clear about whether your policy includes coverage for mental health services, types of services that are covered and the amount paid for these services, and any steps you must take to have treatment covered. You should have received a copy of your insurance policy when you enrolled in the program, whether at work or independently. If you did not receive a copy of the policy or have lost yours, you can call your insurance company and ask for another one to be sent to you.
Even if you have a copy of the plan, it is always helpful to speak to someone else and clarify questions. This way you can identify any possible points of confusion before you receive a bill. You should have a number on your card or on the website that will tell you whom to contact.
The following are some questions you will want to ask your insurance company, if possible, before starting treatment:
1) Do I need a referral from my primary care physician to a mental health professional?
Many insurance companies, especially Health Maintenance Organizations (HMOs) require referrals from a primary care physician to visit any specialist, including mental health professionals. If you do not receive a referral before visiting a mental health professional, your insurance company may deny your claims. If you think you require a referral, you should always get it in advance.
2) Do I need any pre-approval from the insurance company before I see a mental health professional?
A referral is an authorization from a doctor saying that the treatment is medically necessary; pre-approval or pre-authorization­ requires that your insurance company agrees to make the payment. You should call your insurance company to see if you need pre-approval, but you should also keep other questions in mind-how many visits are you approved for? Do you need a new approval for each visit? If you are going to be hospitalized or in inpatient care, how many days are you allowed to stay?
3) Do I need to see a mental health professional who is on a list provided by my insurance company (in a “network”) or am I free to choose any qualified professional?
If you need an “in network” provider, you can usually find a directory online or ask your primary care physician to help pick someone out.
4) Does the amount paid by my insurance company depend on whether I see a professional who is “in their network or preferred provider list” or “outside the network”? If so, what is the difference in the amount paid or percent reimbursement for “in network” vs. “out of network” providers?
“In network” providers are almost always cheaper than “out of network” providers, although whether you want to save money or visit a doctor you prefer is a choice you will have to make. Bear in mind that your insurance company may not always have a flat difference. For some companies, seeing an “in network” provider may cost you a $20 co-pay, and an “out of network” provider will cost you $30; in others, “in network” may cost you $20 and an “out of network” may cost you 20% – which could be significantly higher than $30.
5) Are there dollar limits, visit limits or other coverage limits for my mental health benefits? Is there a difference in what is paid for outpatient vs. inpatient treatment? If so, what are my benefits for each of these?
It is not uncommon, based on your state and your plan, to have limits on psychiatric visits or medication management visits. Your plan may limit you to something like 25 sessions with a psychiatrist each year, up to 7 days of inpatient treatment a year, and 12 medication management visits a year. If you exceed these services, you will have to pay out of pocket.
6) Is there a specific list of diagnoses for which services are covered? If so, is my diagnosis one of those covered by my policy?
Insurance companies often have the option to not include certain diagnoses in all policies. If you applied with your condition as a pre-existing condition, they may not cover anything related to that. Your insurance company will provide you with a list of covered and uncovered diagnoses..
7) What prescription benefit does my policy offer? What are the co-pays for medications? Are there different levels of prescription coverage depending on the specific medication? Do co-payments vary depending on whether the medication is generic or name brand?
Not all health insurance plans offer a prescription benefit plan in addition to a treatment plan. Even if you have a prescription plan, not all medications are covered. Many prescription plans have “formularies” that determine how much you pay for different classes or brands of drugs. Covered medications fall into three categories:
•Generic: These drugs are copies of brand-name drugs that have been on the market for a number of years and are often offered at very cheap prices.
•Preferred: These drugs are name brand but are available to you at a price below the retail price.
•Non-Preferred: These drugs are name brand but are not offered at a very large discount.
Insurance companies regularly update their formularies to classify drugs under certain payment categories. It’s best to ask your doctor to help you find out what payment category your drug is in before you go to the pharmacy to avoid an unpleasant surprise when the bill arrives.
However, many prescription medications for mental health conditions are very expensive and even with health insurance, you can find yourself paying a lot for a prescription.
Mail Order Pharmacy – Some insurance plans will allow you to order a three- month supply of maintenance drugs through the mail for a reduced, standard price.
Seek Outside Assistance – Go here to find out other ways to help pay for your prescription medication.

Seeking Help in Understanding Your Policy
If you have trouble understanding the policy, see if someone from your doctor’s office, your employer, or a trusted friend, can help explain the information.
If you receive health insurance through your employer, you may be able to go to your Human Resources department. If your company is large, you may have a dedicated Benefits Specialist who will be able to help you navigate health care. If you work for a smaller business, you will want to talk to the person who arranged the health care. They may not be able to help and their knowledge may be administrative, but they may help put you in touch with an advocate who can put you on the right track. You may be hesitant to admit to your employer that you need help with a mental health condition, but it is not legal for your employer to fire you over a disability.
If you have private insurance, you can contact your state Insurance Department (http://www.naic.org/state_web_map.htm) or state Insurance Commissioner’s office (http://www.naic.org/documents/consumer_hipaareps.pdf (their consumer hotline may be the most helpful) for help in understanding your insurance policy. They can also help you find out whether your company benefits follow the state mental health parity laws (laws that guarantee equal coverage for mental health conditions as for other health conditions), and can assist you in dealing with your insurance company if you are having a problem.

Funding for mental health services has never achieved top legislative priority, and reforms requiring parity succeeded only after years of hard-fought battles. After the 2007 brush with economic collapse, the recession, staggering unemployment, budget deficits, and sparse tax revenues, however, the situation has grown significantly worse. Dire consequences are predicted for mentally ill individuals who need services and for the communities in which they live.
The degree to which things have deteriorated was outlined during a special Congressional briefing in March sponsored by the National Association of State Mental Health Program Directors (NASMHPD) and the National Association of State Alcohol(Drug information on alcohol) and Drug Abuse Directors. While patient demands on the state public health systems rose 10% from 2009 to 2012, the budgets for 41 states were cut a total of $4.35 billion (the 9 other states have yet to provide data). More crowded emergency departments (EDs), increases in crime and in prison populations, and exponentially greater societal costs to prop up individuals who don’t receive adequate treatment will place even greater stresses on overtaxed systems.

“We have a perfect storm on our hands,” says Joel Miller, NASMHPD’s Senior Director of Policy and Healthcare Reform. “Instead of providing timely, evidence-based mental health services to consumers, we’re going to be spending money in all the wrong places.” The organization’s members—executives from all 50 states, 4 territories, and the District of Columbia—deliver $37 billion of public mental health services to nearly 7 million people each year. Funding, Miller says, will dry up even more over the next several years.

How both the federal and state governments decide to manage the funding shortage during the political battles in a presidential election year is a key question. Mental Health America (MHA), the Washington, DC–based advocacy group, chided congressmen in March and urged House members to reject Rep Paul Ryan’s (R-Wis) budget resolution that proposed slashing Medicaid expenditures.

“I don’t envy the legislators and governors who are making these decisions,” says Sarah Steverman, MHA’s Director of State Policy, “but the budget cuts are short-sighted.” She notes that the across-the-board impact on employers, schools, criminal justice, and homelessness will be magnified as reimbursements to psychiatrists and other mental health practitioners are reduced to meet declining funding.

In Miami-Dade County, Florida, the criminal justice system is feeling effects that are even unusual for a state that has historically ranked near the bottom of public funding for mental health services. In the past 4 years, there has been a noticeable increase in the number of people with serious mental illnesses who end up in the criminal justice system, says Judge Steven Leifman, who has played a key role in developing new ways to reduce unnecessary expenditures incurred when mentally ill people become involved with the justice system. Five years ago, Leifman chaired the mental health sub-committee as the Florida Supreme Court’s special advisor on criminal justice and mental health when it released a comprehensive report—Transforming Florida’s Mental Health System (DOWNLOAD PDF)—that outlined a host of changes.

But with declining resources, the situation has grown worse and won’t likely improve without a major transfusion of money spent appropriately. “The community mental health systems instead of growing are shrinking,” Leifman says. “Access to care was already limited before budget cuts and the systems were horribly fragmented. The budget cuts have only exacerbated the problem.”

Beds that were once available to provide psychiatric care for members of the community have now been diverted to forensic cases—individuals who must be restored to competency before they can stand trial on criminal charges.

“We now spend one-third of all of our public mental health dollars on 1600 forensic beds,” Leifman says. “Not only has it grown exponentially, but it’s also sucking up all the money from the community side.”

Meanwhile, 80% to 90% of the people who pass through the forensic system are soon released back to the community—either because they receive credit for time served, are placed on probation, or have the charges dropped. These people walk out the door, Leifman says, without having ever received the mental health care they actually need. “Spending a third of your money to move them through the system to get them to take a plea and then not give them any services is absurd,” says Leifman. “It’s the definition of insanity, where we keep doing the same thing and expect a different outcome.”

Fixing the problem is difficult when resources are sparse or are used the wrong way, Leifman says. The mentally ill are now the fastest-growing population in Florida’s prisons. Current estimates predict that the state will need to build 10 more prisons in the next 10 years to house increasing numbers.

As mentally ill individuals cycle through the prisons, it’s getting faster and more expensive. “The only silver lining behind the economic downturn is that it’s forcing policymakers to take a look at these absurd policies that are allowing people to circle the drain.”

Nationwide, the numbers reflect Florida’s experience, according to NASMHPD’s report. Over the past 4 years, some 4500 state hospital beds have disappeared without any concomitant improvement in community-based care. As a result, EDs are having to take up the slack: 70% report that they’ve had to “board psychiatric patients” for hours, days, or even weeks at a time.

There are no easy answers to all of these issues, says Laurence Miller, MD, Medical Director for the Arkansas Division of Behavioral Health Services, so the coming round of budget cuts will continue to create a tumultuous environment for public mental health. Dr Miller also serves on the APA’s Council of Healthcare Systems and Financing and chairs the Assembly Committee on Public and Community Psychiatry.

Many states are now in more dire straits than before, and in the face of budget cuts, are making decisions that won’t, in the long run, make sense, he says. For instance, cutting the number of medications available can cause patients who don’t receive what they need to decompensate, which generates even more costs. So, policymakers are “beginning to see the light,” says Miller. “But we still need to compete for the dollars.”

Patients with borderline personality disorder (BPD) are often high users of health care and may present with multiple crises and minor incidents of self-harm or threats.1 As with the boy who cried wolf, inpatient consultants and health care providers may end up feeling manipulated and may not take suicide risk very seriously.
(MORE: Behavioral Dysinhibition: Impulsivity and Borderline Personality Disorder)

Ms A, a 22-year-old, was brought to the emergency department (ED) by ambulance; she had overdosed on zolpidem(Drug information on zolpidem). After detoxification in the ED, a psychiatric consultation was requested. Ms A told the consultant that she had had a bad day and simply took 5 extra zolpidem tablets to “go to sleep” and that “it was just a stupid thing to do.” While obtaining the history, the consultant noted that Ms A’s therapist had left for vacation 2 days earlier.
The consultant informed Ms A that her overdose was just a reaction to her therapist’s vacation, that she did not have a major mental disorder, and that she was going to be discharged. In response, Ms A became irate, “No one cares about me; I just tried to kill myself and you just want to get rid of me! If you don’t admit me, I’m going to walk in front of the next bus!”
Feeling manipulated but with no other options, the consultant admitted Ms A to the inpatient psychiatric unit. Once there, the staff noted that Ms A seemed cheerful, childlike, and cooperative. In the morning, however, Ms A angrily demanded to be discharged when she was refused a smoking pass. The inpatient psychiatrist questioned Ms A about the recent overdose and suicide threats; she stated that she never intended to carry out her threats but was just trying to get attention.
Although health care providers may not take the threat of suicide seriously in patients who have BPD, these patients are often serious about suicide. Long-term studies indicate that compared with controls, patients with BPD have an 8% to 10% increased risk of completed suicide, which is comparable to that of patients who have MDD and schizophrenia.2 Moreover, minor overdoses frequently represent ambivalent suicide intent, and episodes of non-suicidal self-injury are markers for suicide risk and predict future suicide attempts.3,4
Conscious “attention-seeking” behavior is rare, although both patients and health care providers may attempt to frame suicidal behavior that way. As with Ms A, patients may minimize the seriousness of their intent, stating it was just “attention-seeking,” or “I was just trying to sleep,” making it easy for health care providers to question the validity of their patients’ actions.
On the other hand, not every gesture or threat is an indication for a prolonged inpatient hospital stay. Patients may threaten suicide as a way of obtaining or extending hospital stays. A study by Gregory and Jindal5 of 100 consecutive inpatient admissions showed that factitious production of suicide ideation, gestures, and threats was common among women with BPD at the time of discharge. Suicide threats and behavior served as a means of justifying the seriousness of their condition to providers, and to themselves. Given this information, is the underlying message that we should take suicidal ideation and behavior seriously, but not too seriously? How can we understand suicide risk in BPD?

What is already known about suicide risk in patients with borderline personality disorder (BPD)?

■ Patients with BPD are at significant risk for completed suicide; episodes of non­suicidal self-injury predict future suicide attempts.

What new information does this article provide?

■ The article provides a model for understanding suicide risk and behavior in patients with BPD and how that affects clinician-patient interactions.

What are the implications for psychiatrists?

■ Minor overdoses or superficial cutting behaviors are not merely attention-seeking, even if the patient says they are. Are patients placing blame on themselves or on others for recent interpersonal difficulties? If you find yourself in conflict with the patient, realize that the patient likely has an internal conflict over the same issue. A good therapeutic alliance includes clear expectations and boundaries, helping patients build autonomous motivation, and helping patients verbalize experiences and emotions.

Bipolar disorder (BP) is a chronic, debilitating illness that affects 0.4% to 4% of the US population.1,2 The first nosological efforts describing BP appeared in the early 2nd century ad and culminated in Kraepelin’s eloquent description of its phenomenology in his 1921 textbook on manic-depressive insanity.3 Nevertheless, the course and underlying pathophysiology of BP remain elusive.
The disorder is frequently unrecognized, misdiagnosed, and not optimally managed. Moreover, no agent has been specifically developed on the basis of an understanding of the pathophysiology of the illness or mechanism of action of effective treatments.

The current gold standard treatment for BP is lithium, whose mood-stabilizing effects are believed to occur via distinct cellular signaling pathways/targets, such as glycogen synthase kinase 3 inhibition (considered to regulate cellular apoptosis), and other potential downstream cellular mechanisms. In addition to lithium, valproate, and carbamazepine, several atypical antipsychotics (including asenapine) are FDA-approved for the treatment of acute bipolar mania (Table).

While these drugs have certainly provided relief for many individuals with BP, significant issues with tolerability and efficacy remain. For instance, clinicians may find themselves in situations in which better-tolerated agents are less effective, and vice versa. In addition, balancing efficacy with adverse effects that affect adherence, such as sedation and weight gain, underscore the urgent need to develop novel and more effective treatments.

Recent clinical findings

Findings from a meta-analysis indicate that the following agents were more effective than placebo for mania: aripiprazole, asenapine, carba­mazepine, cariprazine, haloperidol, lithium, olanzapine, paliperidone, quetiapine, risperidone, tamoxifen, valproate, and ziprasidone).4 Limited data suggest large effect sizes for carbamazepine, cariprazine, haloperidol, risperidone, and tamoxifen.

Another large meta-analysis evaluated the comparative efficacy of aripiprazole, asenapine, carbamazepine, valproate, gabapentin, haloperidol, lamotrigine, lithium, olanzapine, quetiapine, risperidone, topiramate, and ziprasidone at therapeutic doses for treatment of acute mania.5 The study concluded that antipsychotic drugs were significantly more effective than mood stabilizers; olanzapine, risperidone, and quetiapine were better tolerated than haloperidol. Risperidone, olanza­pine, and haloperidol were particularly efficacious. Most of the trials were short (typically 3 weeks), and therefore caution is needed when extrapolating the results to clinical practice. It is also important to note that because of informed consent and general enrollment issues with manic patients, more severe cases were invariably excluded.

Because strong evidence exists for the use of lithium—and to a somewhat lesser extent, lamotrigine and valproate—as a maintenance treatment for BP, antipsychotics may be increasingly used to treat the acute manic phase of the disorder and mood stabilizers (particularly lithium) may be used for long-term treatment. Nivoli and colleagues6 reviewed the major guidelines for the treatment of manic/hypomanic and mixed episodes and found that all guidelines agreed that concurrent antidepressants should be stopped during a manic/mixed episode.

A focus on the present, dubbed mindfullness can make you happier and healthier. Training to deepen your immersion in the moment works by improving attention.”

Pulling into a parking garage you notice you have no recollection how you got there.
On reaching the bottom of a page in the book , you are frustrated that you have failed to understand what you just read. In conversation, you suddenly become aware that you have no idea what the person speaking to you has just said.

These episodes are symptoms of a distracted mind. You were thinking about a vacation while reading a report or reliving a hurtful exchange with a friend instead of paying attention to the road or conversation.
Whether the mind journeys to the future or the past, whether the thoughts that whisked you away were useful, pleasant, or uncomfortable, the consequences are all the same. You missed the present, experience of the moment , as it was unfolding. Your mind was hijacked into mental time travel.

Distinct from deliberate daydreaming, our mind gets off track. Such mental meandering is tied to negative mood.
Chronic psychological stress, suffered by millions, may be built on a mind consumed by rumination, worry or fear about many topics. This type of diffused and unstable focus impairs performance too. In moments that demand quick decisions and action, the consequences of diverted attention and perception could be deadly.
The opposite of a wandering mind is a mindful one. Mindfulness is a mental mode of being engaged in the present moment without evaluating or emotionally reacting to it.