Bread Recipe

There has been a clamor for the recipe for the Swedish rye bread that has kept me out of the blogosphere for the last few weeks, so I thought I would devote at least one post to that:

Swedish Rye 

(makes 1 full size or 4 small loaves of bread)

First make the sponge:
Scald 1 cup of milk (whole is best, but skimmed works for those of you counting cholesterol)
Pour it onto a mixture:

• 1 tablespoon butter (can substitute margarine)
  
• 1/4 cup honey
  
• 1.5 tsp fennel
  
• 1.5 tsp instant coffee
  
• 1/4 tsp salt (can omit, if you want)
  

While the mixture is cooling, add 1 packet of yeast to 1/4 cup of lukewarm water, and let it bubble. Add it to the scalded milk mixture after that mixture has cooled to lukewarm.
Then add:

• 3 tablespoon sugar
  
• 1.5 tsp orange peel
  
• 1/4 tsp ground cloves
  
• 1 cup of rye flour
  
• 1 cup of whole wheat flour
  
• 1/4 cup white flour.
  

Stir with a wooden spoon for 100 stirs and then leave the sponge to rise for 1-2 hours.

Then make the loaf:

Add 2 cups of white flour to the sponge, gradually kneading until firm and consistent.  Usually takes about 10 minutes for the whole loaf, and another 5 minutes if you choose to break it into small loaves.  Once your loaves are ready, let them rise in a warm place for an hour or two.

Baking:

Preheat oven to 350 degrees.

Bake 50 minutes for full-sized loaf, 35 minutes for small size loaf.

Cool on rack, and then:

Devour with honey or peanut butter (also makes a mean grilled cheese sandwich).  Both the making and the eating of this bread will improve your mental health.  Sunny Solstice, Happy Hannukah, Merry Christmas, Kwazy Kwaanza and a tip top Tet to all!

Christmastime at the Blog: Rosie D at the turning of the year

Been a while since I posted, which doesn't mean that there is nothing going on the in the world of children's mental health reform in Massachusetts.  It mostly means that I have been baking bread, a nice Swedish rye that my nieces call "limpa", but isn't quite.  What it is, is delicious, and a little time consuming, and I've make close to 100 loaves in the last week.  Now if it can just get the gifts wrapped tonight.....

I'm sitting on some interesting stuff, too, that would be worth a bit of commentary:

CMS Update
The State Plan Amendment for Intensive Care Coordination has been officially approved by the Centers for Medicare and Medicaid Services (CMS). We continue to have helpful and productive conversations with CMS about the six remaining Remedy services.

The whole plan depends on Medicaid being able to cover ICC as well as the other intensive home based services, and that requires Federal approval.  It's great that we have approval for the care coordination, but without the other services, then the wraparound will only be partial.  Congratulation to the folks at the CBHI for getting this done, and we can only hope that they can get the rest together soon.

Perhap I'll post the recipe for my Swedish rye bread on Christmas.  Until then, hope that the holidays are treating you well.

Biederman Responds to Charges of Pharma's Influence

Original post, December 7th, 2008:  So, a week later, Dr. Biederman sent out his response to the charges that his Center at MGH has been tainted by Johnson & Johnson's money as it may the world safe for respiridol.  Check out his comments in the Globe here.  Apparently, he was not available for comment when the story broke, but has written a letter to the Globe, in which he points out that he was always transparent about the source of his funding, given that he named to the Center the Johnson and Johnson Center.  I find myself wishing that the Globe had simply published the letter, rather then simply reporting on it.  Would have been more interesting.

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Update, December 18th, 2008:  Dr. Biederman has a letter in today's Wall St. Journal, saying that essentially that the appearance of corruption is in the eye of the beholder. He accuses the Journal of poor journalism.  I applaud the Journal for actually printing the letter.

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Update 27 Dec 2008: Check out Marcia Angell's excellent article in the New York Review of Books on the same subject. This one just won't go away.

More on the Cuba Trip

Not a mental health post, but for those who haven't heard enough about my recent foray to Cuba should check out Fitzhugh Mullan's post on the Health Affairs blog here.  I have some thoughts for some mental health blog posting, but I have been baking a lot late in the night (holiday bread);  more thought to follow.

Blogging One Year On: What Have I Learned So Far.

I noticed that week that it has been one year since my initial foray into blogosphere.  I started the blog in part as a way to chronicle my Physician Advocacy Fellowship, in part to share information that I was acquiring in dribs and drabs about the implementation of the Rosie D. case and the progress of children's mental health reform in Massachusetts and in part to get me to put words on a page in an environment a bit less harsh than that of the academic literature.  So, here we are, 186 posts later (about one every other day) with a regular audience of 10-20 hits daily, mostly within Massachusetts and surrounding states, and blog that has kept me in touch with the movement for Children's Mental Health reform in Massachusetts through the improbable rise of Barack Obama.  What have I learned:

1)  Blogging is an effective way to share information within a small group of dedicated activists.  The blog has been used by hundreds of people seeking information, and is read in the State House as well as in the Berkshires.

2)  Blogging can be an effective way of sharing information with folks behind the firewalls.  I'm a doctor, with no special connections to the organs of power.  I can meet with the folks who make decisions, but it often involves driving to Boston and parking.   Blogging is more efficient.

3)  Interest in blogs grows as they become more useful.  My links are numerous, and I try to comment on what is going on the world.

4)  Blogging in realtime is helpful to folks who can't make the meeting.

I've probably learned more things, but they haven't made the cut.  Going to sleep now.  Please make sure that you keep on reading.

Psychopharmacology and the Evidence: Meeting our New Child Psychiatrist in Chief

UPDATE: The CBHI Provider Conference Call on CANS scheduled for Friday, December 12, 2008, from 12:00 p.m. to 1:00 p.m. has been postponed to January 9, 2009 from 12:00 p.m. to 1:00 p.m.

Much weather in New England today-  the road on which I travel was flooded today, sloowing traffic to a crawl and making me late to Pediatrics Grand Rounds.  Unfortunate, really, as I wanted to hear this one badly.  At UMass, Jean Frazier MD was recently appointed to be the Vice-Chair of Psychiatry and Chief of Child Psychiatry at UMass Medical School.  Her introduction to our Department (Pediatrics, please note) is a talk on the current state of the evidence in the use of atypical antipsychotics in children.  She is a careful researcher, who had one pretty straightforward message for all of us;  while there are a lot of small studies of the use of various atypical antipsychotics in the treatment of bipolar disorder, PDD/autism and early onset schizophrenia, the sample size in general has been small, the outcome measures are limited and that there is not a lot of evidence that the newer agents are really much better than the older medications.  We really need to be doing more studies to understand these medications.  

Her major interest is in the children who are, in the child psychiatry world, the sickest of the sick.  She seemed to be most excited about the TEOSS study,  a study of comparing the use of two of the new drugs(Risperidone and Olanzapine) against one of the first generation of antipsychotics (Molindone) in the treatment of psychosis in children, that was not funded through pharmaceutical funding.  They looked at medication impact, medication side effects and tolerance of long term treatment using a multi-arm randomized controlled trial.  They managed to enroll 119 patients, the largest non-pharma study of these really sick children.  They had lots of weight gain, particularly with olanzipine (Zyprexa), some akanthisa (restless leg syndrome) and elevation in prolaction. The medications are fairly similar treatment outcomes in all three agents .  (molindone: 50%; olanzapine: 34%; risperidone: 46%)   Her main conclusion with that none of these medications were the silver bullet and that these children are very sick, and that careful evaluation of side effects is at least as important as treating the symptoms.   This is the quality of research is really encouraging to see;  she seems a careful prescriber who is acutely aware of how our understanding of psychopharmocology needs to evolve over the next few years.

For clinical practice, she pointed out that, for most of us, we will never see a child with early-onset schizophrenia, and that, in the use of the second-generation antipsychotics for bipolar disorder, it is not clear that high doses of the medication are better.  She is concerned that we are creating a bit of public health problem, as weight gain and even metabolic syndrome, can happen within the treatment.  She urged us to monitor lipids, glucose and hemoglobin A1C, and really push the use of exercise.

One thing I did notice in her compilation of data:  the pharmaceutical industry does not do head to head comparisons of new medications with the older medications-  they will only fund comparisons with a placebo arm.  What is wrong with this, you may ask?  It makes it harder to do detailed comparisons of the relative advantages and disadvantages of the newer and the older (read generic and less costly) medications.  It seems to me, after listening to Dr. Frazier, that one thing that we could do in the government to lessen the "pro-pharma" bias of studies is to create regulations within the FDA that require such studies as a condition of approval.  Probably not as easy as it sounds, but worth pursuing.

It will be nice to have a researcher of this caliber in our midst.

From the CBHI: An Updated timeline

Community Service Agency (CSA) Request for Response (RFR)

Updated Timeline-12/9/08

The deadline for the CSA RFR has been extended to allow those providers – who submitted a letter of intent to bid – additional time to assess their interest in submitting a proposal and to incorporate into their bid the Division of Healthcare Finance and Policy’s final rate determination for Intensive Care Coordination (ICC) and Caregiver Peer to Peer Support Services. The Massachusetts Behavioral Health Partnership (MBHP), in collaboration with the four MassHealth-contracted managed care organizations (MCOs) – Boston Medical Center HealthNet Plan, Fallon Community Health Plan, Neighborhood Health Plan1, and Network Health – announces the following updated CSA RFR procurement timeline:

Milestone Original Date Revised Date
RFR due 1/06/09 1/26/09

Awardees 

announced 2/10/09 3/6/09

Transition 

period 2/11/09  3/6/09

– 6/29/09   – 6/29/09

Implementation 6/30/09 No change

We are also announcing that $3.2 million have been identified to assist with ramp-up needs of each CSA, including costs associated with loss of productivity for staff persons who are in attendance at required, state-sponsored trainings. Disbursement of these funds will depend on the start-up needs for each CSA, which may vary.