Episode 40 - Emotional Support Animals - a podcast by Rio Bravo Family Medicine Residency Program

Episode 40: Emotional Support Animals.

Service Animals vs Emotional Support Animals, meet Ronica and Fred, HTN medications at night, jokes about being 40. 

Today is February 15, 2021.

We hope you had a beautiful Valentine’s Day. Today I’d like to share some information that may be not so new anymore, but for some people it may be new. It’s about hypertension chronotherapy. An article published in AAFP News in November 2019 explains that taking hypertension medication at bedtime improves cardiovascular risk. This was a large prospective study that compared taking meds at bedtime vs taking meds in the morning. It was called The Hygia Chronotherapy Trial. It was originally published in October 2019 in the European Heart Journal. 

The study was conducted in Spain (ole!), and involved almost 20,000 patients with hypertension who were divided into two groups: One group took all their hypertension medications at bedtime, and another group took all their hypertension medications in the morning. In the next 6 years, 1,752 participants experienced cardiovascular-related death, myocardial infarction, coronary revascularization, heart failure or stroke. And the good news is that the bedtime medication group showed an improved blood pressure control and lower risk than the morning medication group. Taking BP medications at bedtime dropped the death rate by 45%. Incidence of myocardial infarction, stroke and heart failure were all significantly reduced. Taking thiazides at bedtime may be challenging, on the bright side, the study also found that moving only one medication to bedtime is still beneficial. 

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. 

Emotional Support Animals

Arreaza: Our guest does not need introduction because you have listened to her voice in several episodes, especially in our recent episode about menopause. Welcome, Valerie Civelli, it’s a pleasure to have you here. Random question, what is the farthest place you have visited? What will be talking about today?

Civelli: Emotional Support Animals (ESA). Many people with disabilities use a service animal in order to fully participate in everyday life. Dogs can be trained to perform many important tasks to assist people with disabilities, such as providing stability for a person who has difficulty walking, picking up items for a person who uses a wheelchair, preventing a child with autism from wandering away, or alerting a person who has hearing loss when someone is approaching from behind.

Arreaza: So, is it like a service animal? 

Civelli: Service animals and emotional support animals are not the same, so be sure to note the different. According to the APA, American Psychology Association:  Species: Any animal can be an emotional support animal. Under federal law, only dogs and miniature horses can be service animals[2]. Such is the case of Abrea Hensley who has flown from Nebraska to Chicago with her miniature mare, Flirty in August 2019. 

Arreaza: There was revival on the topic again. A story went viral in February 2020, one year ago, as Ronica Froese flew from Michigan to Ontario (California) with her service animal who is a miniature horse named Freckle Butt Fred, or Fred for short. They traveled together in first class. The picture went viral online, and it created positive and negative comments among travelers and internauts. Miniature horses were approved as service animals in 2011 by the ADA (Americans with Disability Act).

Civelli: Purpose: An emotional support animal assists through its presence alone. A service animal is specially trained to perform tasks for someone with a disability. Training: An emotional support animal requires no training; all that's needed is a letter from a mental health professional explaining its therapeutic value. Service animals must undergo individualized training. 

Arreaza: Animals for sure generate a reaction in humans whenever they enter a room. Tell us about the legal protections. "An animal's eyes have the power to speak a great language." ― Martin Buber. "An animal's eyes have the power to speak a great language." ― Martin Buber

Civelli: While the Americans with Disabilities Act (ADA) protects service animals, it does not cover emotional support animals. Emotional support animals are covered only under the Air Carrier Access Act and Fair Housing Act. Keep in mind, the criteria of mental or emotional disability is defined in the DSM 5, by the Americans with Disability Act (ADA), the Fair Housing Act, the Rehabilitation Act of 1973 (section 504), as well as the Air Carrier Access Act (49 U.S.C. 41705 and 14 C.F.R. 382).

Arreaza: Where can service animals go?

Civelli: A service animal can go anywhere its owner goes. While owners of emotional support animals may get away with bringing them into places where pets aren't allowed, the only places legally required to welcome them are aircraft—where they fly for free in the main cabin—and housing units.

Arreaza: Or with the owner, and in the case of Fred, the miniature horse. However, Fred probably had his last flight because the US Department of Transportation now allows only service dogs to fly with their human owners in an airplane. Airlines may have different rules, but are required by law to accept service dogs only. So, before you fly with your service animal or emotional support animal, check with your airline. 

Civelli: Let’s talk about ESA letters. They can be written by any licensed mental health professional, such as a therapist, psychologist, or psychiatrist, which should state that pet therapy is an important part of your treatment plan. To get an ESA letter, you must consult professionals who are authorized to prescribe emotional support animal letters in your area. Here is a list of people who can prescribe an ESA Letter:

A Primary Care Physician

A Licensed Therapist

Any Licensed Mental Health Professional

A Licensed General Physician

Arreaza: Elements that should be included on an ESA Letter: It must clearly state the patient suffers from a mental illness that can be managed by an emotional support animal. It should be on proper letterhead

Civelli: And it should contain the following elements:

Licensed person’s name and signature

License number, date of the license, and state where it’s issued

Date of issuance

State 

Patient’s name and date of birth

Pet details-optional

Although not required, it’s recommended to keep the letter updated each year. 

Arreaza: Let’s say you decide to take your service dog to a museum. What questions can employees ask you to determine if your dog is a service animal?

Civelli: In situations where it is not obvious that the dog is a service animal, staff may ask only two specific questions: (1) is the dog a service animal required because of a disability? and (2) what work or task has the dog been trained to perform? Staff are not allowed to request any documentation for the dog, require that the dog demonstrate its task, or inquire about the nature of the person's disability.

Arreaza: Do service animals have to wear a vest or patch or special harness identifying them as service animals?

Civelli: No. The ADA does not require service animals to wear a vest, ID tag, or specific harness.

Arreaza: Anxiety is a very prevalent condition, especially during these times of pandemic. If someone has a dog who calms when having an anxiety attack, does this qualify it as a service animal?

Civelli: It depends. The ADA makes a distinction between psychiatric service animals and emotional support animals. If the dog has been trained to sense that an anxiety attack is about to happen and take a specific action to help avoid the attack or lessen its impact, that would qualify as a service animal. However, if the dog's mere presence provides comfort, that would not be considered a service animal under the ADA.

Arreaza: A sample letter is provided in our website and also as a dot phrase in Epic. Just type .RIOBRAVOESA and a letter will pop up for your patient.

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                                             Sample Template for Emotional Support Animal Letter

 

Date:  2/21/20

ESA Breed: Dog, Golden Retriever

ESA Name: Max

 

To Whom It May Concern:

 

Maria Gonzalez is currently a patient receiving care at our facility.  I am familiar with her/his medical history and with her functional limitations.  This person meets the criteria of mental or emotional disability as defined in the Diagnostic and Statistical manual of Mental Disorders 5 (DSM 5), the Americans with Disability Act (ADA), the Fair Housing Act, the Rehabilitation Act of 1973 (section 504), as well as the Air Carrier Access Act (49 U.S.C. 41705 and 14 C.F.R. 382). This individual has certain limitations associated to social interactions and coping with stressful situations.  

 

To enable his/her ability to live independently and alleviate these difficulties, Maria Gonzalez has an emotional support animal (ESA).  The ESA is necessary to mitigate symptoms experienced. In the setting of airline travel and/or hotel stay, please allow her/him to have the ESA accompanied by her/him at all times as needed. 

 

Sincerely, 

 

    Alan Smith

 

Alan P. Smith, MD

Medical License #: 12345

Date of License Issued: 1/1/1985

NPI #: 17283930

Medical Board of California 

 

Clinical Sierra Vista|7800 E. Niles St.|Bakersfield, CA 93306| 661-328-4284 

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Questions of the Month: Diabetes management 
by Ikenna Nwosu, MD

Hi, I’m Ike, I’m a first-year resident, and today I’m filling in for Dr Carranza, who normally hosts the question of the month. We are happy to inform that we have a winner! Her name is Lubna Nasr. We chose her answer because it’s the most accurate and concise of all the answers. 

Question: 

What is the first treatment approach for type 2 diabetes mellitus? For example, for a patient who had polydipsia, polyuria for a few weeks, and at your office had a random BG of 210. 

 

Ok, let’s call our winner.

 

Answer: The first treatment approach for this patient includes diabetes education, intensive lifestyle modification and Hemoglobin A1c measurement. 

 

Diabetes education: Participation in a comprehensive diabetes self-management education program to learn more about the disease, glucose monitoring, management and complications. 

 

Intensive lifestyle modification (nutrition, physical activity and weight reduction): Nutrition should be based on foods who are low in carbs, include proteins and good fats. 

 

Physical activity: focusing on aerobic exercise (150 minutes weekly or more, at least 3days/week, AND resistance training with free weights or weight machines (2–3 sessions/week). 

 

Hemoglobin A1c measurement: To determine if the patient needs to start treatment with metformin and/or other medications for diabetes, including insulin, if indicated.

 

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For your Sanity: 40
by Steven Saito

This is our 40th episode, so we have some jokes related to being 40 years old. 40 is the perfect age for people. You’re old enough to recognize your mistakes but young enough to make some more. 40 — it’s all fun until it happens to you! You know you’re 40 when your back is hairier than your head. You know you’re 40 when you have a party and the neighbors don’t even realize it. You know you’re 40 when someone offers you a seat on the bus. And you don’t refuse it.

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Now we conclude our episode number 40 “Emotional Support Animals”. Dr. Civelli explained that Emotional Support Animals are companions to provide comfort to patients, but they do not have a particular skill and do not need training. We congratulate Lubna for her concise answer about diabetes management. Diabetes is the bread and butter of primary care, you “gotta” learn diabetes if you want to make a positive impact in your community. We’ll bring you another question next week. Remember, even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Ariana Lundquist, Valerie Civelli, Claudia Carranza, and Ikenna Nwosu. Audio edition: Suraj Amrutia. See you next week! 

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References:

Crawford, Chris, “Taking Hypertension Medication at Bedtime Improves CVD Risk”, AAFP News, https://www.aafp.org/news/health-of-the-public/20191106bedtimehbpmeds.html.

 

O’Kane, Caitlin, “A woman took her 115-pound miniature horse on a plane as a service animal. Now, she's worried it could be his last flight”, CBS News, February 20, 2020, https://www.cbsnews.com/news/miniature-horse-on-plane-woman-took-service-animal-flight-could-be-his-last-airlines/

 

U.S. Department of Justice Civil Rights Division Disability Rights Section, Frequently Asked Questions about Service Animals and the ADA, accessed = February 11, 2021. https://www.ada.gov/regs2010/service_animal_qa.html

 

“Emotional support animal vs. psychiatric service animal”, Monitor on Psychology, American Psychological Association, September 2016, Vol 47, No. 8, https://www.apa.org/monitor/2016/09/pet-aid-sidebar. 

 

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