Archive for the ‘DSM’ Category

DSM-V comments & critiques: the Rosenhan studies rehashed

Friday, August 17th, 2012

It won't be published in its final official form until May of 2013, but the new version of the Diagnostic and Statistical Manual of Mental Disorders, AKA DSM-V,  has already spawned lots of critiques and courses.

My wife, still doing some pro bono therapy, gets at least one offer a week to attend a seminar on DSM-V. I glance at those, but spend much more time on the background comments, including those from the lead editor of DSM-IV.

But let's start with the Rosenhan experiments. In 1973 an academic who was professor of psychology and law at Stanford had eight sane participants (himself among them) present to 12 hospital admission offices in five states with a chief complaint of "hearing voices." They said the messages conveyed were often unclear, but contained the words "empty," "hollow," and "thud."

In each case the voice was unfamiliar and of the same gender as the complainant (the group included one younger psychology graduate student, three professional psychologists, one psychiatrist, a pediatrician, a painter and a housewife). They gave false names, vocations and employment history, but all other details of their lives were true.

All were admitted to psychiatric wards, whereupon they acted completely sane and behaved as they normally would.

None of the staff recognized they were normal and 10 of them were given the diagnosis of schizophrenia. They remained in the hospital for a week to 52 days (average of  19 days) where a number of other patients suspected they were sane (35 of 118 did so with many vocalizing that the so-called patients were journalists or professors).

When the results of the study were initially made known, the staff of a week-known teaching/research hospital said they wouldn't make such mistakes.

At that point, Dr. Rosenhan set up a second experiment, telling the staff of the renowned center that he would send them  one or more spurious patients over the next three months.

In reality he sent nobody, yet the hospital staff, suspected a number of the 193 patients who were admitted during that time frame; the physicians, psychologists, nurses and techs alleged that 41 were fakes and, of those, 23 were suspected by one or more psychiatrists.

During their admissions all of the first group publicly took copious notes and the typical comment in the nursing notes was "Patient engaged in writing behavior."

They were only discharged with a diagnosis of schizophrenia in remission after admitting they were crazy and all were given medications  (which they did not swallow; they noted many patients did the same).

They seldom saw physicians except for fleeting encounters; in only 6% of these did staff doctors stop and chat or talk with them.

One comment about this famous study is, "It's hard to be sane in an insane setting?

Sorry, I can't give you links or photos, but I'm on an unplanned trip and using my iPad instead  of my laptop.

The MH Romp part 2: Why so many codes?

Friday, July 27th, 2012

medical bills are complex

Today I got a mini-brochure in the mail from the American Medical Association, AKA the AMA, offering the CPT 2013 Professional Edition and the ICD-9-CM 2013 Professional Edition with a special offer; more than 40% off if I order both by September 1, 2012. That's $114.66 versus the package list price of $202.90. WOW!

Okay, what are those things and why would I (or rather a physician still seeing patients) want them? CPT is the acronym for Current Procedural Terminology, a series of numeric codes developed and periodically updated by the AMA that are used for billing patients or insurance companies for each and every service that a doc may provide to a non-Medicare patient. If the person seen by a physician is over 65 (or is otherwise eligible for Medicare), then a set of codes called HCPCS are used for billing purposes. The acronym stands for Healthcare Common Procedure Coding System. Level I HCPCS codes are identical to CPT codes. Level II codes cover things that don't usually get billed by a physician such as ambulance services or durable medical equipment. Medicare and Medicaid handle those differently than insurance companies do.

But I want to focus on Mental Health issues and eventually get into two other sets of handbooks, both with their own codes. So first some history.

The initial development of MH illness groupings in the US dates back to the 1840 census when a category for "idiocy/insanity" was added. Forty years later, census data included seven MH entities, some of which would be classified as medical diseases now (e.g., epilepsy).

There's a nice history of the DSM itself on an American Psychiatric Association (APA) website. It's been an amazing saga leading to multiple disputes and perhaps even some acrimony. Basically WW II heavily influenced the development of the DSM and, for that matter, the ICD. It was the first time large numbers of US psychiatrists, headed by Brigadier General William Menninger, got directly engaged in all aspects of military personnel selection, processing, assessment and treatment.

Medical 203, a brand new classification of MH disorders came out in 1943 as a War Department Technical Bulletin. All the Armed Forces and, with slight alterations, the Veterans Administration, adopted this nomenclature. When psychiatrists returned to private practice, after the War, they brought Medical 203 to their hospitals and clinics.

The World Health Organization added MH diagnoses in their International Classification of Diseases (ICD) with the 6th revision in 1949. Prior to that the ICD had primarily been used to classify the causes of death in various populations, an effort dating back at least to the mid 1850s.

The forward to DSM-I mentions the ICD-6 "categorized mental disorders in rubrics {names, titles, groups} similar to those of the Armed Services nomenclature." But the APA formed a committee to standardize a version to be used in the Untied States. A tenth of the total membership of the APA eventually had a chance to voice their opinions and over 90% liked the adaptation, eventually titled the Diagnostic and Statistical Manual of Mental Disorders, DSM for short.

In 1998, L.J. (Lawrence) Davis, a long-term writer and contributing editor for Harper's Magazine, published an article titled, "The Encyclopedia of Insanity: A Psychiatric Handbook lists a madness for everyone." He was referring, of course, to the DSM, in this case to DSM-IV.It's a harsh critique, saying the DSM was dogmatic with a theme that we're all either crazy or about to be, but treatable, by guess who...the selfsame authors of the 866-page-long book.

For those of us with medical insurance, we can let the third-party payer sort things out

So there have been numerous versions of the ICD and we're about to see DSM-V in May of 2013. Both have billing codes which are identical in large part. Most psychologists use DSM, but third-party payers use the American version of ICD-9-CM (the CM stands for Clinical Modification).

But there's still controversy and disagreement and the HHS Secretary announced that as of October 1, 2013, the ICD-10-CM codes must be used. The rest of the world has used these since 1990.

Yet DSM-V is supposedly coming out in May, 2013 and ICD-11 is due in 2014.




Romping through the Mental Health field: part one: various clinicians and MH medications

Tuesday, July 24th, 2012

talk therapy often helps

Although my training was in Internal Medicine (IM) with a subspecialty in Nephrology (nephros is Greek for kidney), I've had a long-standing interest in Mental Health (MH) issues. My medical school (University of Wisconsin circa 1962-1966) included four years of MH classes. Then I supervised, in various Air Force roles, mental health departments and later commanded a hospital with 90 MH beds (versus 15 each of IM, Peds, Ob-Gyn & Surgery). But there's an even more important reason for me to care about the wife is a clinical social worker, i.e., one who sees patients (they now call them "clients," but I don't) with MH problems.

Since I'm married to a MH therapist, I'm familiar with the Diagnostic and Statistical Manual for Mental Disorders, DSM for short. It'a a publication of the APA, the American Psychiatric Association and is the "lingua franca," the standard terminology for all working in the MH field. That includes psychiatrists, who are, of course, MDs and therefore can prescribe medications (I often get the impression that's all many of them do these days), psychologists (PhDs who, in general, can't, although two states, New Mexico and Louisiana, have enabled some who obtain a master's degree in clinical psychopharmacology to write RXs for MH meds only), clinical social workers (who have a Masters degree or, occasionally, a PhD, but can't prescribe pills), and a variety of other therapists (e.g., marriage and family therapists), most of whom have a Masters degree and can't prescribe meds.

Of course those of us who have MD degrees and aren't MH specialists can also order MH meds; internists and family practice physicians do so fairly often. I saw our FP today for  my sore hand and raised the subject; my impression was she'd be uncomfortable writing kids' MH prescriptions, but is quite at home with adults. I'd think that most surgeons and Ob-Gyn physicians would be less likely to write RXs for many of these drugs without consulting another physician who's used to the meds and their side effects. The standard anti-anxiety drugs would be an exception, of course, and perhaps they might treat a patient with relatively mild depression.

Whenever I saw a patient with significant depression or other major MH issues I put in a call to the psychiatrists.

So who is available to treat this youngster?
Mostly likely his pediatrician.

I didn't know much about pediatric mental health issues. I found an online paper titled "Strategies to Support the Integration of Mental Health into Pediatric Primary Care" from an organization I at first thought was part of the NIH. Then I Googled it and realized the National Institute for Health Care Management wasn't governmental, but a non-profit. The Executive Summary of "Strategies" stated up to one in five children and adolescents in the U.S. experience MH issues with 50% of all lifetime mental disorders being seen by age 14.

The issue for Pediatrics is there aren't very many psychiatrists who specialize in kids; so three ideas have been suggested: telemedicine for remote Pediatric practices; co-locating a pediatric psychiatrist in a large Peds practice or collaborative care via what's called the "medical home model." But for Pediatrics in general, the integration of MH care into primary care is desperately needed; again there just aren't enough Peds therapists to see all the youngsters with MH issues.

I'll get back to the DSM in my next post; its history is interesting and its latest version, to be published in May 2013, has caused a lot of controversy.