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Medicaid Expansion as reported in Knoxville

6/22/2014

KNOXNEWS.COM

Decision on Medicaid Expansion holds coverage for many Tennesseans in balance

By Kristi Nelson

Posted June 2, 2013, updated June 4 2013

It was supposed to be one of the strongest tenets of the 2010 Patient Protection and Affordable Care Act. Instead, it became a political football, a metaphor for states’ rights. After the Supreme Court ruled that the ACA could not force states to expand Medicaid, Gov. Bill Haslam was among those who rejected the Medicaid expansion, instead offering his alternative “Tennessee Plan” for federal government approval.

But whether the federal government and the General Assembly will accept Haslam’s plan remains to be seen, along with how well it will work to cover those who currently don’t have health insurance.

“He’s either politically brilliant, or he’s making one of the worst mistakes he could make,” Rep. Joe Armstrong, D-Knoxville, told the News Sentinel in March.

What the ACA intended

Originally, the Medicaid expansion provision was to give state health insurance coverage to a group of people who made too much to qualify for Medicaid but too little to afford insurance on the health insurance exchanges, even with the planned government subsidies.

It expanded Medicaid to qualify people younger than 65 whose income is below 138 percent of the federal poverty guideline (a little more than $15,860 annually for an individual, a little less than $32,500 annually for a family of four).

It meant that, for the first time, low-income adults who don’t have children could get state Medicaid coverage, and it standardized other qualifications.

Many states, including Tennessee, limit Medicaid enrollment to certain categories of people. To qualify for TennCare, for example, you have to be low-income and pregnant, a child, blind, disabled, aged, or fall under multiple, specific categories.

Tennessee has nearly 1 million uninsured residents, of whom at least 140,000 and maybe more than twice that number, by some estimates, likely would enroll in Medicaid if it were expanded under the ACA guidelines. About three-quarters would have been previously uninsured. Under the ACA expansion, the federal government would pick up the entire cost of new, previously ineligible enrollees for the first three years, phasing to 90 percent by 2020. In Tennessee, federal funds would have amounted to about $1.4 billion in the first year alone.

States could receive federal matching funds for covering additional low-income residents under Medicaid as early as April 2010, with wide-scale enrollment beginning this October and coverage starting Jan. 1, 2014. However, in June 2012, the U.S. Supreme Court ruled that the federal government could not make states expand Medicaid — making a linchpin of the ACA optional.

So far, 20 states have moved forward with Medicaid expansion. Ten have rejected it outright, while 10 others are not doing it now but are looking at alternatives and have not ruled it out for the future (the government gives no deadline, though states waiting much longer to decide stand to lose federal funds for the first year). Three states are still undecided, while seven — including Tennessee — are crafting their own, alternate plans.

On March 27, Gov. Bill Haslam announced that Tennessee would not expand TennCare rolls under the ACA, instead offering up an alternative he called the Tennessee Plan.

“I don’t think just pure expanding of a system that we all agree is too costly for us, is too costly for the federal government to afford long-term, is the right way,” he said then.

The ‘Tennessee Plan’

Haslam’s proposal is that the state use federal funds not to expand TennCare but to purchase private insurance through the insurance exchange for people who would have qualified for coverage under Medicaid expansion.

He outlined the proposal in the broadest terms, including five “key points”:

Individuals identified as being eligible for the Medicaid expansion group would instead be directed to the exchange, where they would be allowed to choose any qualified health plan that offers a certain level of benefits (the Silver Plan).

The state would pay the monthly premiums, matchable with 100 percent federal dollars, for those people to enroll in the Silver Plan.

People in the Medicaid expansion group would be treated like all other people enrolled in the Silver Plan, with access to the same benefits and appeals process as other people in the plans.

People in the Medicaid expansion group would have the same cost-sharing as other Silver Plan enrollees with incomes below 250 percent of the federal poverty guidelines. (On average, Silver Plan policies would pay for 70 percent of health care costs, with the remaining 30 percent paid by the planholder.)

The arrangement would have a “circuit-breaker,” or “sunset,” ending after the three-year period of 100 percent federal matching dollars, and could be renewed only with approval of the General Assembly. (This is true for states accepting the Medicaid expansion as well; they can stop using federal funds and drop the expanded coverage at any time.)

In addition, Haslam would seek to reform the way providers are paid for services, with payment based on outcomes rather than a set fee for services. The money saved, he said, would be enough to cover the state’s 10 percent share of costs after the government’s share goes to 90 percent.

“One option for covering the Medicaid expansion group is simply to add them to the Medicaid rolls, or the TennCare rolls, in our case,” Haslam said of the plan. “We don’t want to do that. There are a lot of federal requirements that come with Medicaid that make it difficult to provide quality care in the most cost-effective way possible.”

But the federal government may not allow Haslam to forgo some of those requirements. While national Centers for Medicare and Medicaid Services guidelines indicate that the main tenets of the plan — using federal dollars to pay premiums for low-income people to have commercial insurance, and reforming payment — meet federal requirements, some of the details don’t align with federal requirements intended to protect Medicaid enrollees.

For example, Tennessee would need to give those with serious health conditions a choice of enrolling in TennCare or private insurance, unless CMS were to grant Tennessee a waiver to that requirement.

The federal government would require supplementation of benefits (sometimes called “wraparound”) to make sure the commercial insurance plans include all services that would be available through Medicaid. Hypothetically, this could be done through a supplemental premium to the Silver Plan insurance provider.

The government also limits co-payments for Medicaid-eligible enrollees.

There is also an appeals process in place, required by past Supreme Court rulings, so that Medicaid patients and their doctors can challenge insurance companies’ refusals to cover “necessary treatments.” Under federal law, Tennessee would have to allow Medicaid-eligible patients this due process.

A federal entitlement program, Medicaid was designed for a population upon whom “poverty imposes special needs and the need for special protections,” said Carole Myers, a nurse practitioner and associate professor in the University of Tennessee’s College of Nursing. “They don’t have the same voice in government as those with different economic statuses and organizational affiliations.”

Haslam acknowledged in April that Tennessee probably would have to limit co-payments and provide the wraparound services for Medicaid-eligible enrollees for the federal government to approve his alternative, but he said he still thinks his overall plan is “workable.”

What’s next?

Haslam’s plan is modeled on a plan by Arkansas, which also wants to use federal matching dollars to pay commercial insurance premiums for those eligible for the Medicaid expansion. But while Arkansas got legislators’ approval before approaching the federal government, Haslam has taken the opposite approach, presenting his plan to CMS first.

Haslam did not ask state legislators to vote on whether to take the federal Medicaid expansion funds this session, though he said he has not ruled out calling a special legislative session later this year to meet federal deadlines for the health exchange enrollment starting in October.

The Medicaid expansion is the only provision in the ACA that provides insurance coverage specifically to those between 101 percent and 138 percent of the federal poverty guideline. If Haslam fails to reach an agreement with the federal government, or does not opt to accept the federal Medicaid expansion plan (which he could still do), that population likely would remain uninsured.

However, the latest word among hospital executives and advocates is that an agreement could be near.

“I think (Health and Human Services) Secretary (Kathleen) Sebelius is really eager to find some alternative plans that meet the goals of the ACA but do so in creative ways and allow states to create plans beneficial to those individual states,” said Jerry Askew, senior vice president for governmental relations for Tennova Healthcare.

Through Tennova’s parent company, Health Management Associates, Askew works with hospitals in seven states. All of them, except those in Kentucky and West Virginia, have said no to the expansion.

“They’re all trying to figure out what to do. It’s really interesting to watch how the state is to meet their individual objectives,” Askew said. As for Tennessee, he added, “It is fair to say that the governor’s plan is being built on principles that the majority in the Legislature would agree with. But it’s not a given. It’s a lot of hard work.”

Consumer-advocate groups and hospitals were in favor of the expansion, especially since hospitals stand to lose money on uncompensated “charity” care that would have been partially covered, at least, if more people were insured through Medicaid. The Tennessee Hospital Association has said the state stands to lose 90,000 jobs and nearly $13 billion.

Having that population continue to go uninsured also means higher costs in the long run, Myers said, as studies have shown that those without insurance are less likely to get preventive or early care.

“When you are resorting to getting care only when it becomes so bad you can’t stand it, and you’re in the emergency room, it’s causing a major human toll,” she said. “We know that intervention on the earliest point of the illness trajectory is the most cost-efficient. The true measure of whether we’re successful in what we’re doing in health care is in whether people have long, happy, productive lives.”

Business writer Carly Harrington contributed to this report.

© 2013, Knoxville News Sentinel Co.

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NIMH information on treatment Borderline Personality Disorder

5/9/2014

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What is borderline personality disorder?Borderline personality disorder is a serious mental illness marked by unstable moods, behavior, and relationships. In 1980, the Diagnostic and Statistical Manual for Mental Disorders, Third Edition (DSM-III) listed borderline personality disorder as a diagnosable illness for the first time. Most psychiatrists and other mental health professionals use the DSM to diagnose mental illnesses.

Because some people with severe borderline personality disorder have brief psychotic episodes, experts originally thought of this illness as atypical, or borderline, versions of other mental disorders.1 While mental health experts now generally agree that the name "borderline personality disorder" is misleading, a more accurate term does not exist yet.

Most people who have borderline personality disorder suffer from:

Problems with regulating emotions and thoughts
Impulsive and reckless behavior
Unstable relationships with other people.

People with this disorder also have high rates of co-occurring disorders, such as depression, anxiety disorders, substance abuse, and eating disorders, along with self-harm, suicidal behaviors, and completed suicides.

According to data from a subsample of participants in a national survey on mental disorders, about 1.6 percent of adults in the United States have borderline personality disorder in a given year.2

Borderline personality disorder is often viewed as difficult to treat. However, recent research shows that borderline personality disorder can be treated effectively, and that many people with this illness improve over time.1,3,4

What are the symptoms of borderline personality disorder?According to the DSM, Fourth Edition, Text Revision (DSM-IV-TR), to be diagnosed with borderline personality disorder, a person must show an enduring pattern of behavior that includes at least five of the following symptoms:

Extreme reactions—including panic, depression, rage, or frantic actions—to abandonment, whether real or perceived
A pattern of intense and stormy relationships with family, friends, and loved ones, often veering from extreme closeness and love (idealization) to extreme dislike or anger (devaluation)
Distorted and unstable self-image or sense of self, which can result in sudden changes in feelings, opinions, values, or plans and goals for the future (such as school or career choices)
Impulsive and often dangerous behaviors, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge eating
Recurring suicidal behaviors or threats or self-harming behavior, such as cutting
Intense and highly changeable moods, with each episode lasting from a few hours to a few days
Chronic feelings of emptiness and/or boredom
Inappropriate, intense anger or problems controlling anger
Having stress-related paranoid thoughts or severe dissociative symptoms, such as feeling cut off from oneself, observing oneself from outside the body, or losing touch with reality.

Seemingly mundane events may trigger symptoms. For example, people with borderline personality disorder may feel angry and distressed over minor separations—such as vacations, business trips, or sudden changes of plans—from people to whom they feel close. Studies show that people with this disorder may see anger in an emotionally neutral face5 and have a stronger reaction to words with negative meanings than people who do not have the disorder.6

Suicide and Self-harmSelf-injurious behavior includes suicide and suicide attempts, as well as self-harming behaviors, described below. As many as 80 percent of people with borderline personality disorder have suicidal behaviors,7 and about 4 to 9 percent commit suicide.4,7

Suicide is one of the most tragic outcomes of any mental illness. Some treatments can help reduce suicidal behaviors in people with borderline personality disorder. For example, one study showed that dialectical behavior therapy (DBT) reduced suicide attempts in women by half compared with other types of psychotherapy, or talk therapy. DBT also reduced use of emergency room and inpatient services and retained more participants in therapy, compared to other approaches to treatment.7 For more information about DBT, see the section, "How is borderline personality disorder treated?"

Unlike suicide attempts, self-harming behaviors do not stem from a desire to die. However, some self-harming behaviors may be life threatening. Self-harming behaviors linked with borderline personality disorder include cutting, burning, hitting, head banging, hair pulling, and other harmful acts. People with borderline personality disorder may self-harm to help regulate their emotions, to punish themselves, or to express their pain.8 They do not always see these behaviors as harmful.

When does borderline personality disorder start?Borderline personality disorder usually begins during adolescence or early adulthood.1,9 Some studies suggest that early symptoms of the illness may occur during childhood.10,11

Some people with borderline personality disorder experience severe symptoms and require intensive, often inpatient, care. Others may use some outpatient treatments but never need hospitalization or emergency care. Some people who develop this disorder may improve without any treatment.12

Studies suggest early symptoms may occur in childhood

What illnesses often co-exist with borderline personality disorder?Borderline personality disorder often occurs with other illnesses. These co-occurring disorders can make it harder to diagnose and treat borderline personality disorder, especially if symptoms of other illnesses overlap with the symptoms of borderline personality disorder.

Women with borderline personality disorder are more likely to have co-occurring disorders such as major depression, anxiety disorders, or eating disorders. In men, borderline personality disorder is more likely to co-occur with disorders such as substance abuse or antisocial personality disorder.13

According to the NIMH-funded National Comorbidity Survey Replication—the largest national study to date of mental disorders in U.S. adults—about 85 percent of people with borderline personality disorder also meet the diagnostic criteria for another mental illness.2

Other illnesses that often occur with BPD include diabetes, high blood pressure, chronic back pain, arthritis, and fibromyalgia.14,15 These conditions are associated with obesity, which is a common side effect of the medications prescribed to treat borderline personality disorder and other mental disorders. For more information, see the section, "How is borderline personality disorder treated?"

What are the risk factors for borderline personality disorder?Research on the possible causes and risk factors for borderline personality disorder is still at a very early stage. However, scientists generally agree that genetic and environmental factors are likely to be involved.

Studies on twins with borderline personality disorder suggest that the illness is strongly inherited.16,17 Another study shows that a person can inherit his or her temperament and specific personality traits, particularly impulsiveness and aggression.18 Scientists are studying genes that help regulate emotions and impulse control for possible links to the disorder.19

Social or cultural factors may increase the risk for borderline personality disorder. For example, being part of a community or culture in which unstable family relationships are common may increase a person's risk for the disorder.1 Impulsiveness, poor judgment in lifestyle choices, and other consequences of BPD may lead individuals to risky situations. Adults with borderline personality disorder are considerably more likely to be the victim of violence, including rape and other crimes.

How is borderline personality disorder diagnosed?Unfortunately, borderline personality disorder is often underdiagnosed or misdiagnosed.20,21

A mental health professional experienced in diagnosing and treating mental disorders—such as a psychiatrist, psychologist, clinical social worker, or psychiatric nurse—can detect borderline personality disorder based on a thorough interview and a discussion about symptoms. A careful and thorough medical exam can help rule out other possible causes of symptoms.

The mental health professional may ask about symptoms and personal and family medical histories, including any history of mental illnesses. This information can help the mental health professional decide on the best treatment. In some cases, co-occurring mental illnesses may have symptoms that overlap with borderline personality disorder, making it difficult to distinguish borderline personality disorder from other mental illnesses. For example, a person may describe feelings of depression but may not bring other symptoms to the mental health professional's attention.

No single test can diagnose borderline personality disorder. Scientists funded by NIMH are looking for ways to improve diagnosis of this disorder. One study found that adults with borderline personality disorder showed excessive emotional reactions when looking at words with unpleasant meanings, compared with healthy people. People with more severe borderline personality disorder showed a more intense emotional response than people who had less severe borderline personality disorder.6

What studies are being done to improve the diagnosis of borderline personality disorder?Recent neuroimaging studies show differences in brain structure and function between people with borderline personality disorder and people who do not have this illness.22,23 Some research suggests that brain areas involved in emotional responses become overactive in people with borderline personality disorder when they perform tasks that they perceive as negative.24 People with the disorder also show less activity in areas of the brain that help control emotions and aggressive impulses and allow people to understand the context of a situation. These findings may help explain the unstable and sometimes explosive moods characteristic of borderline personality disorder.19,25

Another study showed that, when looking at emotionally negative pictures, people with borderline personality disorder used different areas of the brain than people without the disorder. Those with the illness tended to use brain areas related to reflexive actions and alertness, which may explain the tendency to act impulsively on emotional cues.26

These findings could inform efforts to develop more specific tests to diagnose borderline personality disorder.6

How is borderline personality disorder treated?Borderline personality disorder can be treated with psychotherapy, or "talk" therapy. In some cases, a mental health professional may also recommend medications to treat specific symptoms. When a person is under more than one professional's care, it is essential for the professionals to coordinate with one another on the treatment plan.

The treatments described below are just some of the options that may be available to a person with borderline personality disorder. However, the research on treatments is still in very early stages. More studies are needed to determine the effectiveness of these treatments, who may benefit the most, and how best to deliver treatments.

PsychotherapyPsychotherapy is usually the first treatment for people with borderline personality disorder. Current research suggests psychotherapy can relieve some symptoms, but further studies are needed to better understand how well psychotherapy works.27

It is important that people in therapy get along with and trust their therapist. The very nature of borderline personality disorder can make it difficult for people with this disorder to maintain this type of bond with their therapist.

Types of psychotherapy used to treat borderline personality disorder include the following:28

Cognitive behavioral therapy (CBT). CBT can help people with borderline personality disorder identify and change core beliefs and/or behaviors that underlie inaccurate perceptions of themselves and others and problems interacting with others. CBT may help reduce a range of mood and anxiety symptoms and reduce the number of suicidal or self-harming behaviors.29
Dialectical behavior therapy (DBT). This type of therapy focuses on the concept of mindfulness, or being aware of and attentive to the current situation.1 DBT teaches skills to control intense emotions, reduces self-destructive behaviors, and improves relationships. This therapy differs from CBT in that it seeks a balance between changing and accepting beliefs and behaviors.30
Schema-focused therapy. This type of therapy combines elements of CBT with other forms of psychotherapy that focus on reframing schemas, or the ways people view themselves. This approach is based on the idea that borderline personality disorder stems from a dysfunctional self-image—possibly brought on by negative childhood experiences—that affects how people react to their environment, interact with others, and cope with problems or stress.31

Therapy can be provided one-on-one between the therapist and the patient or in a group setting. Therapist-led group sessions may help teach people with borderline personality disorder how to interact with others and how to express themselves effectively.

One type of group therapy, Systems Training for Emotional Predictability and Problem Solving (STEPPS), is designed as a relatively brief treatment consisting of 20 two-hour sessions led by an experienced social worker. Scientists funded by NIMH reported that STEPPS, when used with other types of treatment (medications or individual psychotherapy), can help reduce symptoms and problem behaviors of borderline personality disorder, relieve symptoms of depression, and improve quality of life.32 The effectiveness of this type of therapy has not been extensively studied.

Families of people with borderline personality disorder may also benefit from therapy. The challenges of dealing with an ill relative on a daily basis can be very stressful, and family members may unknowingly act in ways that worsen their relative's symptoms.

Some therapies, such as DBT-family skills training (DBT-FST), include family members in treatment sessions. These types of programs help families develop skills to better understand and support a relative with borderline personality disorder. Other therapies, such as Family Connections, focus on the needs of family members. More research is needed to determine the effectiveness of family therapy in borderline personality disorder. Studies with other mental disorders suggest that including family members can help in a person's treatment.33

Other types of therapy not listed in this booklet may be helpful for some people with borderline personality disorder. Therapists often adapt psychotherapy to better meet a person's needs. Therapists may switch from one type of therapy to another, mix techniques from different therapies, or use a combination therapy. For more information see the NIMH website section on psychotherapy.

Some symptoms of borderline personality disorder may come and go, but the core symptoms of highly changeable moods, intense anger, and impulsiveness tend to be more persistent.34 People whose symptoms improve may continue to face issues related to co-occurring disorders, such as depression or post-traumatic stress disorder.4 However, encouraging research suggests that relapse, or the recurrence of full-blown symptoms after remission, is rare. In one study, 6 percent of people with borderline personality disorder had a relapse after remission.4

MedicationsNo medications have been approved by the U.S. Food and Drug Administration to treat borderline personality disorder. Only a few studies show that medications are necessary or effective for people with this illness.35 However, many people with borderline personality disorder are treated with medications in addition to psychotherapy. While medications do not cure BPD, some medications may be helpful in managing specific symptoms. For some people, medications can help reduce symptoms such as anxiety, depression, or aggression. Often, people are treated with several medications at the same time,12 but there is little evidence that this practice is necessary or effective.

Medications can cause different side effects in different people. People who have borderline personality disorder should talk with their prescribing doctor about what to expect from a particular medication.

Other TreatmentsOmega-3 fatty acids. One study done on 30 women with borderline personality disorder showed that omega-3 fatty acids may help reduce symptoms of aggression and depression.36 The treatment seemed to be as well tolerated as commonly prescribed mood stabilizers and had few side effects. Fewer women who took omega-3 fatty acids dropped out of the study, compared to women who took a placebo (sugar pill).

With proper treatment, many people experience fewer or less severe symptoms. However, many factors affect the amount of time it takes for symptoms to improve, so it is important for people with borderline personality disorder to be patient and to receive appropriate support during treatment.

How can I help a friend or relative who has borderline personality disorder?If you know someone who has borderline personality disorder, it affects you too. The first and most important thing you can do is help your friend or relative get the right diagnosis and treatment. You may need to make an appointment and go with your friend or relative to see the doctor. Encourage him or her to stay in treatment or to seek different treatment if symptoms do not appear to improve with the current treatment.

To help a friend or relative you can:

Offer emotional support, understanding, patience, and encouragement—change can be difficult and frightening to people with borderline personality disorder, but it is possible for them to get better over time
Learn about mental disorders, including borderline personality disorder, so you can understand what your friend or relative is experiencing
With permission from your friend or relative, talk with his or her therapist to learn about therapies that may involve family members, such as DBT-FST.

Never ignore comments about someone's intent or plan to harm himself or herself or someone else. Report such comments to the person's therapist or doctor. In urgent or potentially life-threatening situations, you may need to call the police.

How can I help myself if I have borderline personality disorder?Taking that first step to help yourself may be hard. It is important to realize that, although it may take some time, you can get better with treatment.

To help yourself:

Talk to your doctor about treatment options and stick with treatment
Try to maintain a stable schedule of meals and sleep times
Engage in mild activity or exercise to help reduce stress
Set realistic goals for yourself
Break up large tasks into small ones, set some priorities, and do what you can, as you can
Try to spend time with other people and confide in a trusted friend or family member
Tell others about events or situations that may trigger symptoms
Expect your symptoms to improve gradually, not immediately
Identify and seek out comforting situations, places, and people
Continue to educate yourself about this disorder.

Where can I go for help?If you are unsure where to go for help, ask your family doctor. Other people who can help are:

Mental health professionals, such as psychiatrists, psychologists, social workers, or mental health counselors
Health maintenance organizations
Community mental health centers
Hospital psychiatry departments and outpatient clinics
Mental health programs at universities or medical schools
State hospital outpatient clinics
Family services, social agencies, or clergy
Peer support groups
Private clinics and facilities
Employee assistance programs
Local medical and psychiatric societies.

You can also check the phone book under "mental health," "health," "social services," "hotlines," or "physicians" for phone numbers and addresses. An emergency room doctor can provide temporary help and can tell you where and how to get further help.

What if I or someone I know is in crisis?If you are thinking about harming yourself, or know someone who is:

Call your doctor.
Call 911 or go to a hospital emergency room to get immediate help or ask a friend or family member to help you do these things.
Call the toll-free, 24-hour hotline of the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255) or TTY: 1-800-799-4TTY (4889) to talk to a trained counselor.
If you are in a crisis, make sure you are not left alone.
If someone else is in a crisis, make sure he or she is not left alone.

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Blum N, St John D, Pfohl B, Stuart S, McCormick B, Allen J, Arndt S, Black DW. Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: a randomized controlled trial and 1-year follow-up. Am J Psychiatry. 2008 Apr;165(4):468–78.
Hoffman PD, Fruzzetti AE. Advances in interventions for families with a relative with a personality disorder diagnosis. Curr Psychiatry Rep. 2007 Feb;9(1):68–73.
McGlashan TH, Grilo CM, Sanislow CA, Ralevski E, Morey LC, Gunderson JG, Skodol AE, Shea MT, Zanarini MC, Bender D, Stout RL, Yen S, Pagano M. Two-year prevalence and stability of individual DSM-IV criteria for schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders: toward a hybrid model of axis II disorders. Am J Psychiatry. 2005 May;162(5):883–9.
Binks CA, Fenton M, McCarthy L, Lee T, Adams CE, Duggan C. Pharmacological interventions for people with borderline personality disorder. Cochrane Database Syst Rev. 2006;(1):CD005653.
Zanarini MC, Frankenburg FR. omega-3 Fatty acid treatment of women with borderline personality disorder: a double-blind, placebo-controlled pilot study. Am J Psychiatry. 2003 Jan;160(1):167–9.

For more information on borderline personality disorderVisit the National Library of Medicine's:

MedlinePlus

En Español

For information on clinical trials

National Library of Medicine clinical trials database

Information from NIMH is available in multiple formats. You can browse online, download documents in PDF, and order materials through the mail. Check the NIHM website for the latest information on this topic and to order publications. If you do not have Internet access, please contact the NIMH Information Resource Center at the numbers listed below.

National Institute of Mental Health
Science Writing, Press & Dissemination Branch
6001 Executive Boulevard
Room 8184, MSC 9663
Bethesda, MD 20892-9663
Phone: 301-443-4513 or 1-866-615-NIMH (6464) toll-free
TTY: 301-443-8431 or 1-866-415-8051 toll-free
FAX: 301-443-4279
E-mail:
Website: http://www.nimh.nih.gov

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Larry Drain announces the next speaker in Maryville

4/15/2014

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April 24.
More on our speaker series
by hopeworkscommunity
We recently announced the beginning of our speaker series in Blount County sponsored by Maryville Nami. Our first speaker on March 20 will be Sita Diehl National Director of State Advocacy for Nami national. I am very excited today to announce our second speaker today. On April 24 Doug Varney Commissioner for Dept of Mental Health and Substance Abuse will be coming to speak in Maryville. Tentatively his topic will be the scourge of drug abuse, particularly prescription drugs and meth, their relationship to mental health issues and efforts by the state to address these issues. It should be a great and informative evening. Please do all you can to spread the word about both of these presentations.

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Larry Drain: Open Letter to Governor Haslam

2/19/2014

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A very personal plea for medicaid expansion: a letter to the governor

By Hopeworkscommunity

Dear Governor Haslam:
I want to start by first thanking you for your decision to restore funding to peer support centers in Tennessee. As a mental health advocate I can tell you it is one of the best decisions you have ever made and I am so thankful you made it.

But my decision to write this letter is about much more than the peer support centers. In your state of the state message you talked a couple of times about the importance of government giving good customer service. You seemed to put a lot of stock in that idea. It was not the first time I have heard you speak about it. The decision to fund peer centers was a great example of good customer service.

My hope is that you will consider my request in the light of that concept. I am in a desperate situation and without your help I dont know where to turn.

I want to ask you to reconsider your stance on medicaid expansion. I know you are in a tough spot. Anything that makes the Tea Party mad faces great obstacles in Tennessee and few things make them angrier than health care reform. Perhaps what I am asking you is impossible for you to politically do. Several people have told me it is.

As I said my situation is desparate. Let me take a minute to describe it.

I have been “free” of health care insurance for many years. It is a freedom I would gladly lose. I have been told that I need surgery. The surgery is a minor one that thousands of people undergo every year. No insurance means no surgery. The doctor tells me the lack of surgery though may not be a minor thing though, that in fact if my condition should become an emergency my life may be in danger. I pray every day not to die a preventable death. Many people have far more dangerous situations than me and face far more immediate risk. Being poor should never, at least not in Tennessee be the cause of anyone’s death. And without action on your part it will be though.

My desperation though is not based purely on issues of my health. It goes far deeper than that.

My wife is disabled and has been on TennCare for a while. She is a TennCare miracle. Without it she would have died long ago. Even with all her progress without it she would no live a month. In order to save her insurance and in a very real sense her life after 32 years of marriage we have had to separate. I dont know, without TennCare expansion we can ever live together again.

The situation is very complex, but let me share it with you as briefly as I can. My wife receives SSI for disabilities. Recently I took retirement from Social Security. It was the worst decision I have ever made.

We found out that in Social Security’s eyes, even though our combined checks left us below poverty, we made far too much money. Linda lost over $700 and her check was reduced to $20 a month. I told Social Security that I would have to get a job in order for us to survive. We figured without her check we had about $40 to live on for the month of January and we just cant live like that. Who could??

Social Security told us that since her TennCare was disability based and not income based (like it would be if TennCare was expanded) that if I made over $85 a month her TennCare would be lost.

I love my wife and wont let her die. The day after Christmas we separated. The hope is that with a separate address she can regain her SSI check. My hope is to move as close to her as possible. Right now I do not see how we can ever live together again.

You do not make the rules for Social Security and none of that is your fault. The law is what it is and despite its cruelty and hurtfulness we have no choice but to do our best to live with it. A law that supports the break up of thousands of marriages seems so evil, but I dont right now see how I can affect it.

I am asking for your help though. Maybe I dont have the right but I have no where else to turn. I know you deeply love and care for your wife. What would you say to me if our situations were reversed??

Please act. Whatever the resolution please act. My wife will keep her TennCare. I will never do anything to put that in jeopardy. Without your help though my marriage will not survive and for Linda and I that is a death of a different sort.

.

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All 45 Peer Support Centers Survive, Thanks for Raising Your Voices

2/3/2014

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Larry Drain, Legislative Liaison for DBSA Tennessee, published the flowing blog on his Hope Works Community blog site this evening. He is responsible for DBSA Tennessee's advocacy effort beginning with his Nov. 25, 2013 blog to bring attention to the crisis. Larry wrote:
"Now word has come that funding for peer support centers is to be totally stopped. The fate of 45 centers and all the people they serve is uncertain at best. The department has managed to find the smallest possible cut that affects the most possible people."

At Larry's recommendations, DBSA Tennessee became the first statewide consumer organization to take action; first, with a Christmas card to the Governor Campaign and, later, an online petition to urge Governor Haslam to cancel plans to close the centers. Recruiting organizational leadership, Larry was the first to post an "Open Letter to the Governor" from the State Director, DBSA Tennessee.

Additionally, Larry's strong desire to save the peer support centers led him to write numerous blogs, place numerous phone calls, and speak directly to leaders and advocates representing peer service organizations. He can take pleasure in the fact that his efforts were fruitful. And he can be comforted that thousands of the most vulnerable of our brother and sister consumers can enjoy the safe haven of 45 peer support centers in the days to come.

We applaud Larry for his work and perseverance. Thanks, Larry.
Steve

Peer Support lives
February 3, 2014
hopeworkscommunity blog

It was announced tonight in Governor Haslam’s 2014 budget for the state of Tennessee that proposed budget cuts that would have closed all 45 peer support centers in Tennessee has been rescinded and all peer support centers will be fully funded.

Thanks to a governor who listened and to so many who spoke out.

It has been a good night for all of us.

Much to be thankful for. Glad to have some good news to share.

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Speak with the decision-makers

1/28/2014

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The attached document contains a ‘pairing’ of PSC’s with their area’s Senator & Representative. For those of you planning on attending Mental Health Day on the Hill, this year, I’m hoping you can take some consumers with you. It would be great if you can use this document, early on,& go ahead & call your area legislators for appointment times. M H ‘Day on the Hill is March 18ththis year.

I would like to know when you set appointments, so I can try to be with you. Obviously, the huge issue for Mental Health Consumers is the matter of Governor Haslam’s desire to eliminate funding for the Peer Centers. Let’s all in regions VI, & VII “put it together”, & influence our Legislators as to how important pro-mental health legislation is. And particularly how very important it is to keep our Peer Support Centers running. You can let me hear from you by, or by my cell #:

PEER SUPPORT CENTERS IN TENNESSEE

REGION I

FRONTIER HEALTH SERVICES
Host Agency Contact: Mary Fultineer
26 Midway Street
Bristol TN 37620

CONTACT:SENATOR RON RAMSEY--

REPRESENTATIVE JON LUNDBERG--

Open Arms
Coordinator: Angela Prater

1400 Windsor Avenue
Bristol, TN 37620
Open: Monday-Thursday 8:30 am - 6:30 pm
Counties Covered: Sullivan

CONTACT:SENATOR RON RAMSEY--

REPRESENTATIVE JON LUNDBERG--

Friendship House
Coordinator: Glenda Edwards

805 West Walnut Street
Johnson City, TN 37604
Open: Tuesday-Thursday 8 am – 5 pm
Counties Covered: Unicoi, Washington, Carter

CONTACT:SENATOR RUSTY CROWE--

REPRESENTATIVE MATTHEW HILL--

Friendship Connection
Coordinator: Melissa Frazier

117 Wexler Street
Kingsport, TN 37660
Open: Monday-Thursday 9 am-6 pm
Counties Covered: Sullivan

CONTACT:SENATOR RON RAMSEY--

REPRESENTATIVE TONY SHIPLEY--

Freedom Peer Support Center – Greeneville
Coordinator: Charles McLain

616 East Church Street
Greenville, TN 37743
Open: Mon, Tues, Thurs, Fri 11 am-5 pm
Counties Covered: Greene, Hawkins

CONTACT:SENATOR STEVE SOUTHERLAND--

REPRESENTATIVE DAVID HAWK--

Higher Ground
Coordinator: Charles Justice

1404 Crossroads Drive
Mountain City, TN 37683
Open: Tues, Wed, Thurs, Fri 9 am-5 pm
Counties Covered: Johnson

CONTACT:SENATOR RON RAMSEY--

REPRESENTATIVE TIMOTHY HILL--

New Start - Sneedville
Coordinator: Charles McLain

119 Nora Alder Drive
Sneedville, TN 37689
Open: Tues, Wed, Thurs, Fri 12-5 pm
Counties Covered: Hancock

CONTACT:SENATOR FRANK NICELEY--(615)

REPRESENTATIVE MIKE HARRISON--(423)

REGION II

CHEROKEE HEALTH SYSTEMS
Host Agency Contact: Stella Melton
or
215 Hedrick Drive
Newport, TN 37821

CONTACT:SENATOR STEVE SOUTHERLAND--(423)

REPRESENTATIVE JEREMY FAISON--(615)

Health Recovery Group-Morristown
Peer Counselor: Mike Clayton

815 W 5th North Street
Morristown, TN 37814
Hours: Mon, Wed, Fri 1-4 pm
Counties covered: Hamblen, Cocke

CONTACT:SENATOR STEVE SOUTHERLAND---(423)

REPRESENTATIVE TILMAN GOINS--(423)

Health Recovery Group-Newport
Peer Counselor: Mike Clayton
or
215 Hedrick Drive
Newport, TN 37821
Hours: Tues &Thurs 1-4 pm
Counties covered: Hamblen, Cocke

CONTACT:SENATOR STEVE SOUTHERLAND--(423)

REPRESENTATIVE JEREMY FAISON--(615)

RIDGEVIEW PSYCHIATRIC HOSPITAL & CENTER
Host Agency Contact: Sharon Stratton

240 West Tyrone Road
Oak Ridge, TN 37830

CONTACT:SENATOR RANDY MCNALLY--(865)

REPRESENTATIVE JOHN RAGAN--(865)

Friendship Place
Coordinator: Linda King

201 Sewanee Street #100
Harriman, TN 37748
Open: Tues – Fri 12 PM to 5:30 PM
Counties Covered: Morgan

CONTACT:SENATOR KEN YAGER--(865)

REPRESENTATIVE KENT CALFEE--(615)

Horizons
Coordinator: Linda White

11 Joel Lane
Oak Ridge, TN 37830
Open: Wed – Sat 12 PM to 5:30 PM
Counties Covered: Anderson

CONTACT:SENATOR RANDY MCNALLY--(865)

REPRESENTATIVE JOHN RAGAN--(865)

Wings
Coordinator: Barbara Smith

1327 East Central Avenue, Suite 5
Lafollette, TN 37766
Open: Wed – Thurs, 11 AM - 6; Fri, 11 AM – 7 PM Sat, 10 AM – 6 PM
Counties Covered: Campbell

CONTACT:SENATOR KEN YAGER--(865)

REPRESENTATIVE DENNIS POWERS--(615)

HELEN ROSS MCNABB CENTER
Host Agency Contact: Jana Morgan

526 Lamar Street
Knoxville, TN 37917

CONTACT:SENATOR STACY CAMPFIELD--(865)

REPRESENTATIVE GLORIA JOHNSON--(865)

Friendship House

Coordinator: Michelle Palmer

526 Lamar Street
Knoxville, TN 37917
Open: Tues., Thurs. & Sat. 10 AM to 2 PM
Wed. & Fri. 10 AM to 6 PM
Counties Covered: Knox

CONTACT:SENATOR STACY CAMPFIELD--(865)

REPRESENTATIVE GLORIA JOHNSON--(865)

PENINSULA BEHAVIORAL HEALTH
Host Agency Contact: Mary Nelle Osborne

1451 Dowell Springs Blvd Suite 101
Knoxville, TN 37909-2451

CONTACT:SENATOR STACY CAMPFIELD--(865)

REPRESENTATIVE STEVE HALL--

Maryville Wellness Recovery Center
Coordinator: Joey Amason

532 E. Broadway Avenue
Box 9
Maryville, TN 37804
Open: Mon – Thus, 10:00 AM – 4:00 PM
Counties Covered: Blount

CONTACT:SENATOR DOUG OVERBEY--

REPRESENTATIVE ART SWANN--

Sevierville Wellness Recovery Center
Coordinator: Marjorie Diefenbach

509 High Street
Sevierville, TN 37862
Open: Mon – Thur, 11 am – 6 pm
Counties Covered: Sevier

CONTACT:SENATOR DOUG OVERBEY--

REPRESENTATIVE DALE CARR--

Knox Wellness Recovery Center
Interim Coordinator: Leslie Judson

1451 Dowell Spring Road
Knoxville, TN 37919
Open: Tuesday- Thursday 3-7
Counties Covered: Knox

CONTACT:SENATOR STACY CAMPFIELD--

REPRESENTATIVE STEVE HALL--

REGION III

FORTWOOD CENTER
Host Agency Contact: Dot Stephens

1028 East 3rd Street
Chattanooga, TN 37403

CONTACT:SENATOR TODD GARDENHIRE--

REPRESENTATIVE JOANNE FAVORS--

Lighthouse Peer Support Center
Coordinator: Marty Davis

509 South Highland Park
Chattanooga, TN 37403-4116
Open: Monday – Thursday 10:00 AM – 6:00 PM
Saturday – 10:00 AM – 3:30 PM
Counties Covered: Hamilton

CONTACT:SENATOR TODD GARDENHIRE--

REPRESENTATIVE JOANNE FAVORS--

VOLUNTEER BEHAVIORAL HEALTH CARE SYSTEM
Host Agency Contact: Vicki Harden

The Cottage
Coordinator: Paul Turney

112 College Street
Jasper, TN 37347
Open: Mon, Wed, Fri 9:30 AM – 6:00 PM
Tues &Thurs 10:30 AM – 7:00 pm
Counties Covered: Marion, Grundy

CONTACT:SENATOR JANICE BOWLING--

REPRESENTATIVE BILLY SPIVEY--

Dakoda Place - Athens
Coordinator: Tina Gesolgon

PO Box 685
424 Old Riceville Road
Athens, TN 37303
Open: Monday – Friday 9:00 AM – 3:00 PM
Counties Covered: McMinn

CONTACT:SENATOR MIKE BELL--

REPRESENTATIVE JOHN FORGETY--

Dakoda Place - Cleveland
Coordinator: Tina Gesolgon

940 South Ocoee Street
Cleveland, TN 37311
Open: Tues & Thurs 9:00 AM – 3:00 PM
Counties Covered: Bradley

CONTACT:SENATOR MIKE BELL--

REPRESENTATIVE KEVIN BROOKS--

Friends & Company
Coordinator: Angela Smithers
or
1200 S. Willow Avenue
Cookeville, TN 38503
Open: Tues 12-5; Wed - Fri 9-5
Counties Covered: Putnam, White

CONTACT:SENATOR CHARLOTTE BURKS--

REPRESENTATIVE RYAN WILLIAMS--

Friendship Circle
Coordinator: Becky Porter

412 Delaware Avenue
Dayton, TN 37321
Open: Monday – Friday 9:00 AM – 5:00 PM
Counties Covered: Rhea

CONTACT:SENATOR KEN YAGER--(865)

REPRESENTATIVE RON TRAVIS--

My Friends House
Coordinator: Linda Joan Smith

209 B South Church Street
Livingston, TN 38570
Open: Monday – Friday 9:00 AM – 5:00 PM
Counties Covered: Overton, Clay, Pickett

CONTACT:SENATOR CHARLOTTE BURKS--

REPRESENTATIVE JOHN MARK WINDLE--

PREPS Center
Coordinator: Sandra Crabtree

47 Willow Street
Crossville, TN 38555
Open: Mon - Fri 8:00 AM – 4:00 PM
2nd Friday 8:00 AM – 12:00 PM
2nd Saturday 9:00 AM – 1:30 PM
Counties Covered: Cumberland

CONTACT:SENATOR CHARLOTTE BURKS--

REPRESENTATIVE CAMERON SEXTON--

Harmony House
Coordinator: Mary Webb

107 Lyon Street Suite 3
McMinnville, TN 37110
Open: Monday - Thursday, 8 am to 2 pm
Counties covered: Warren

CONTACT:SENATOR JANICE BOWLING--

REPRESENTATIVE CHARLES CURTISS--

REGION IV

CENTERSTONE

Host Agency Contact: Mary Moran

1101 Sixth Avenue North
Nashville, TN 37208

CONTACT:SENATOR THELMA HARPER--

REPRESENTATIVE MIKE TURNER--

ReConnect Nashville
Coordinator: Greg Bennett
or
1101 Sixth Avenue North
Nashville, TN 37208
Open: Monday – Friday 10 – 4 open one Saturday per month
Counties Covered: Davidson

CONTACT:SENATOR THELMA HARPER--

REPRESENTATIVE MIKE TURNER--

REGION V

CENTERSTONE
Host Agency Contact: Mary Moran

1101 Sixth Avenue North
Nashville, TN 37208

CONTACT:SENATOR THELMA HARPER--

REPRESENTATIVE MIKE TURNER--

ReConnect Clarksville
Regional Coordinator: Carla Sanders
or
611 8th St.
Clarksville, TN 37040
Open: Mon – Fri 10 – 4; open one Saturday per month
Counties Covered: Montgomery, Robertson

CONTACT:SENATOR MARK GREEN--

REPRESENTATIVE JOE PITTS--

ReConnect Dickson
Regional Coordinator: Carla Sanders
or
224 N Main ST
Dickson, TN 37055-1802
Open: Mon – Fri 10 – 4; open one Saturday per month
Counties Covered: Dickson

CONTACT:SENATOR JIM SUMMERVILLE--

REPRESENTATIVE DAVID SHEPARD--

ReConnect Tullahoma
Regional Coordinator: Brenda Hargrove

709 North Davidson St
Tullahoma, TN 37388
Open: Mon – Fri 10 – 4; open one Saturday per month
Counties Covered: Coffee, Lincoln

CONTACT:SENATOR JANICE BOWLING--

REPRESENTATIVE JUDD MATHENY--

ReConnect Columbia
Regional Coordinator: Wanda Yeager
or
6011 Trotwood Avenue
Columbia, TN 38401
Open: Mon – Fri 10 – 4; open one Saturday per month
Counties Covered: Maury, Lawrence

CONTACT:SENATOR JOEY HENSLEY--

REPRESENTATIVVE SHEILA BUTT--

ReConnect Shelbyville
Contact Person: Brenda Hargrove
or
1110 Woodbury Street
Shelbyville, TN 37160
Open: Mon – Fri 10 – 4; open one Saturday per month
Counties Covered: Bedford

CONTACT:SENATOR JIM TRACY--

REPRESENTATIVE PAT MARSH--

VOLUNTEER BEHAVIORAL HEALTH CARE SYSTEM
Host Agency Contact: Vicki Harden

Enrichment House
Coordinator: Effie Cates

538 East Main Street
Gallatin, TN 37066
Open: Tues – Fri 8:00 AM – 5:00 PM
Counties Covered: Sumner, Wilson

CONTACT:SENATOR FERRELL HAILE—(

REPRESENTATIVE WILLIAM LAMBERTH--

Our Place
Coordinator: Lyndi Shupp

120 S. Hancock Street
Murfreesboro, TN 37130
Open: Mon – Thurs & Sat 9:00 AM – 3:00 PM
Counties Covered: Rutherford

CONTACT:SENATOR BILL KETRON--

REPRESENTATIVE RICK WOMICK--

REGION VI

CAREY COUNSELING CENTER
Host Agency Contact:
Sherri Sedgebear

PO Box 793
Huntingdon, TN 38344

Liberty Place
Coordinator: Priscilla Johnson

111 East Eaton St
Trenton, TN 38382
Open: Tues – Fri 10-8; Sat 8-4
Counties Covered: Gibson

CONTACT:SENATOR JOHN STEVENS--

REPRESENTATIVE CURTIS HALFORD--

Outreach Center
Coordinator: Kathy Graham

1539 Hwy 69 North
Paris, TN 38242
Open: Tues- Fri 10-6; Sat 8-4
Counties Covered: Henry

CONTACT:SENATOR JOHN STEVENS--

REPRESENTATIVE TIM WIRGAU--

C.A.R.E.S. Center
Coordinator: Teresa Madison

946 Flatwoods Road
Camden, TN 38320
Open: Thurs – Fri 9-4; Sat 9-3
Counties Covered: Benton

CONTACT:SENATOR JOHN STEVENS--

REPRESENTATIVE TIM WIRGAU--

Sunrise Outreach Center
Coordinator: Shawna Williams

110 East Church Street
Union City, TN 38261
Open: Tues – Fri 10-6; Sat 8-4
Counties Covered: Obion

CONTACT:SENATOR JOHN STEVENS--

REPRESENTATIVE ANDY HOLT--

PATHWAYS
Host Agency Contact: Pat Taylor

238 Summar Dr
Jackson, TN 38301

CONTACT:SENATOR LOWE FINNEY--

REPRESENTIVE JOHNNY SHAW--

The Hope Center
Coordinator: Debbi Young

222 E. Court St. Suite A
Dyersburg, TN 38024
Open: Tues – Thurs 8:00 AM – 3:30 PM
Counties Covered: Crockett, Dyer, Lake

CONTACT:SENATOR LOWE FINNEY--

REPRESENTATIVE BILL SANDERSON--

Rainbow Center
Coordinator: Thomas Byars

67 American Drive
Jackson, TN 38301
Open: Tue, Wed & Thurs 8:00 AM – 4:00 PM
Counties Covered: Madison, Haywood

CONTACT:SENATOR LOWE FINNEY--

REPRESENTATIVE JIMMY ELDRIDGE--

Comfort Center
Coordinator: Kim Buckley

300 Holly Street
Lexington, TN 38351
Open: Mon - Fri 8:00 AM-4:00 PM
Counties Covered: Henderson