Sentinels

 

 

2014 - 2013 - 2012 - 2011

April 15 - April 1 - March 16 - March 5 - February 21 - January 19 - January 3

April 15

Folks,

There are 3141 counties in this country. About half have not a single psychiatrist.  Montgomery County has 387 listed in the 2014 Edition of The Washington Physicians Directory.  And the “387” does not include some in the public sector. And almost all of you, I believe, are as busy as you want to be.  And some of you have waiting lists.  And the book does not list non-physicians [of which the County has many outstanding non-MD psychotherapists].

Seniors admitted to ICUs for more than 48 hours and given ramelteon, 8 mg/d for 7 days were less likely to develop delirium in a controlled study [JAMA Psychiatry, April 2014].

AJP, this month:

1] Possible assumption going into psychotherapy with a patient: “Women’s depressions are defined by deficiencies in caring relationships and interpersonal loss and men’s by failure to achieve expected instrumental goals and lowered self-worth.”  Can’t demonstrate, however, that therapist beginning with those two assumptions do any better than those who do not.

2] Also interesting and hypothetical:  Bringing the computer into clinical settings “has the possibility to help us invoke personas that reach the patient emotionally in a way we cannot.”

3] All antidepressants may potentially cause liver injury.  Nevertheless, liver injury from antidepressants is a rare event, although in some cases it is irreversible.  As there is no way to prevent antidepressants adverse hepatic events, early detection and prompt discontinuation remain critical.  Further research, however, is required before rigorously founded recommendations can be established for clinical practice.

4] Topiramate for 12 weeks, maximum dose, 200 mg/d, reduced heavy drinking in problem drinkers.  Article suggested that there may be genetic ways to identify those who would benefit from use of topiramate.

5] Study suggests brain injury leads to “an increased risk of schizophrenia, depression, bipolar disorder, and organic mental disorders.”   

In this month’s JAACAP, page 479, the statement, “. . .more than 90% of suicide completers in the general population meet criteria for at least 1 mental illness versus military rates no higher than 50%.”  But, how does one claim someone did not meet an NOS diagnosis?

The article, in JAPS this month, “Why Patients Should Avoid Physicians Who Submit to Specialty Board Re-Certification, has a winning argument as to the worthlessness and expense of the RE-certification exam, but present a very weak argument on how that harms patients. \

From the NEJM this week, on this anniversary of the Boston Marathon Bomb Explosion, an article describing the treatment at Mass General of one of the survivors who lost a leg , had many shrapnel wounds and burns of 38% of his skin.  Hospitalized for 45 days and months in rehab, he underwent about two dozen operations.  Psychiatric issues were addressed through adequate pain management, assuring sleep, allowing fiancée to accompany the clinical team on morning rounds, and having military amputees visit him.  At a meeting recently, he was asked: "we are an academic institution, so what could we learn from you that we could improve on?” His answer:  “I can’t think of anything, expect maybe the food.”

Roger

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April 1

Folks,

Today, only one item, the diagnoses expected when we bill.

On Monday, Congress completed its work on the "doc fix" bill, the bill to fix the payment of clinicians with Medicare patients.  Within that bill, a paragraph postponing the implementation of ICD-10-CM till at least October 1, 2015.  This leaves us with ICD-9-CM that we have being using for about two decades.  Challenge is that since May 22, 2013, there are two versions of ICD-9-CM, DSM-IV-TR’s and DSM-5”s. 

Over time, it is assumed that more and more payers will expect clinicians to use DSM-5’s version of ICD-9-CM.  It would be nice if the powers in Maryland, Insurance Commissioner [?] set a date for all to use DSM-5’s version of ICD-9-CM, a date that coincided with the Medicare’s, Kaiser’s, and the VA’s implementation of the DSM-5 version, but that seems improbably.  Thus, we may face some payers expecting billings to use DSM-IV-TR’s version of DSM-9-CM and some payers expecting us to use DSM-5.

It could be argued that the payers only pay attention to codes, and both use the same codes, so no problem, right?  Restated, DSMs have to use ICD-9-CM codes, the difference between the DSM-IV-TR’s version and the DSM-5’s are:

1] Names of the Disorders.  About 75 have a different name, often a minor change, “Pedophilic Disorder” replaces “Pedophilia.”  Some major, “Genito-pelvic Pain/Penetration Disorder” replaces “Dyspareunia.”

2] Combining of Disorders, DSM-5 has combined about fifty DSM-IV-TR Disorders, so many of those Disorders are no longer in DSM-5’s version of ICD-10-CM, e.g., Asperger’s Disorder and it’s code are not in DSM-5.

3] Bringing in 50 or more Disorders in ICD-9-CM that were not in DSM-IV-TR, e.g., Premenstrual Dysphoric Disorder

4] Introducing about ten Disorders not in ICD-9-CM, but, of course, having to use ICD-9-CM codes, e.g., Disruptive Mood Dysregulation Disorder was given code 296.99, already in ICD-9-CM as “Other Specified Episodic Mood Disorder.”

One simple solution would be that Maryland would decide that all payers would recognize all ICD-9-CM codes, regardless of nomenclature.  This proposal, I assume would be consistent with parity, that we are treated the same as the rest of medicine.  I would guess that some would see problems with that solution.

Back to ICD-10-CM.  We only know that it was postponed until after October 1, 2015, and, as of noon today, no one was willing to take “credit” for that paragraph in the law.  AMA declined to take credit, even though opposed to implementing ICD-10-CM in the near future – or ever.  Bottom line, ICD-10-CM’s starting date is unknown. 

Some have suggested leap-frogging ICD-10-CM and focusing on getting ready for ICD-11-CM, which might be available in 2018, but more likely 2020.

For those of us with neophobia, this has been a good week.

Roger

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March 16

Folks,

This week’s New Yorker has an eight page article on the Sandy Hook killings. Key point in the middle of the article from Paul Appelbaum, past APA President and as influential as any psychiatrist in this century: "many young men are asocial and unhappy, spend too much time online, become video-game addicts -- but cause no harm.  The few dangerous ones are impossible to identify."  We need to remind some of our colleagues of Paul’s last sentence.  

The American Board of Psychiatry and Neurology’s website has exams in 2015 and 2016 only focusing on “classifications and diagnostic criteria that have not changed from DSM-IV-TR to DSM-5.”  We pointed that only ten DSM disorders so qualify, so further clarification was attempted at the ABPN website, but it is still very unclear.  A motion passed by the Washington Psychiatric Society last Monday asks that we be examined only on DSM-5 in 2015, not some combination of DSM-IV-TR and DSM-5.  Motion now goes to the APA’s Assembly.  Keep in mind that if the APA does adopt our motion, ABPN is an independent entity and can ignore the APA’s position.

In adolescents who have bipolar I or II disorder, after an illness episode, intensive psychotherapy combined with best-practice pharmacotherapy does NOT appear to confer advantages over brief psychotherapy and pharmacotherapy in hastening recovery or delaying recurrence [AJP Advance, this month].

March issue of the Schizophrenia Bulletin, researchers’ recommendation for the minimum effective doses:

aripiprazole 10 mg
asenapine 10 mg
clozapine, 300 mg
haloperidol, 4 mg
iloperidone 8 mg
lurasidone 40 mg
olanzapine 7.5 mg
paliperidone 3 mg
quetiapine 50 mg
risperidone, 2 mg
sertindole, 12 mg
ziprasidone, 40 mg”

In this month’s AACAP journal a very through review of whether inflammation is an etiological agent of psychiatric disorders.  [A rationale to use aspirin for people with depression (Int Clin Psychopharmacology 2006;21:227-231)].  Article concluded that given the overlap among psychiatric disorders, proinflamatory markers are UNLIKELY to serve as diagnostic biomarkers.  Another conclusion, I would submit, is that DSM’s division of psychopathology is blocking psychiatry from identifying markers.  No markers identified since DSM-III [1980] outside those disorders we share with neurology .

Some results consistent with DSM being problematic is a study in this month’s J Clin Oncology of breast cancer survivors that found yoga decreased fatigue, increased vitality, decreased some inflammatory markers, but did not decrease in depression as defined by DSM.

Another angle to the inflammation story is that an animal study reported last summer suggested that a splenectomy prevents PTSD from developing after mental trauma. [biopsych.2013.11.029]  
As we said in Sentinel # 29, Value Options expects us to use the DSM-5 version of ICD-10-CM, not DSM-IV-TR’s.  The Feds version of ICD-10-CM is DSM-IV-TR’s.  Thus downloading the Feds version will not give you the DSM-5 nomenclature.  In April, we will provide the DSM-5 version of ICD-10-CM for you. 

There is already one in DSM-5, pages 877 to 896, but it may not contain some Disorders you would like to use.  Please let me know of Disorders you would like to see available.  For example, some of you, as well as your patients and  the pediatricians you are working with, may want to continue to use Asperger’s.  ICD-10-CM has a separate code, F84.5, from Autism, F84.0.   

Today’s Wall Street J says that those of you who are still alive in 2100 will have your vision perfect, hearing sharply focused, able to recall any past events, and so forth via cloud-based messaging through minute electrodes into your brain.  Not mentioned in the article is the possibility that having minute electrodes into the amygdala, nucleus acumens, VTA, cerebellum, other areas to where all can have long-lasting, exquisite orgasms at any time, making heroin passé -- and addressing any concerns about over-population.

Tired of using the word, ”integration,” so politically correct, for decades, as a goal since the mentally ill left the well-integrated [but, for many, inhumane] public hospital?  Do you want to sound sophisticated?  Avant garde?  Under thirty?  Instead, use “interoperability.”  A couple of weeks ago, Malcolm Gladwell came to town and about a thousand showed up to hear him talk about how to achieve interoperability in healthcare.  Drawing on examples from his book, David and Goliath, he said we needed to reframe the healthcare question to achieve interoperability.  How to reframe the question, he left to audience.

Roger 

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March 5

Folks,

Been busy on a number of projects and late with a new Sentinel, but I think the following should not wait.  While the feds are demanding a switch from ICD-9-CM to ICD-10-CM on October 1 this year, states get to decide whether it should be the DSM-IV-TR version of ICD-10-CM or the DSM-5 version.  

For Maryland: Mental Health Administration has given Value Optons the approval to make the change to DSM V, that is doing away with the axis system and using the new diagnoses, beginning July  2014 for  provider entries into Provider Connect (the way providers request authorizations online).  For claims submissions, ICD-9 will be used until October 1, 2014 after which all claims must have ICD-10-CM diagnoses.  It was a dozen years ago that the Washington Psychiatric Society called for the abolition of the Multiaxial System.. Takes perseverance to achieve some goals.

As you know, Maryland Medicaid does not cover all ICD-9-CM/DSM-IV-TR conditions.  Over the next few months we will probably see the Mental Health Administration provide an updated list of the Priority Population Diagnoses and Medicaid will be providing a list of all covered Public Mental Health System diagnoses.  Value Options, always prompt as to policies in my experience, will send out Provider Alerts with this information as soon as they have those approved lists. 

Roger
Folks,

Some additional information relative to the announcement in Sentinel # 29.

For those wanting information on ICD-10-CM and related topics, you can download the Resource for Psychiatrists in Montgomery County, Maryland [RPMCM-2014-01-12] at Roger Peele.com.

1] Introduction

2] Comprehensive listing of psychiatric conditions including

A] ICD-9-CM
B] CD-10-CM codes in italics for many disorders 
C] DSM-5
D] Practice Guidelines in blue
E] FDA approved medications in red

3] Outline of history of the ICDs

4] Numerical listing of ICD-9-CM 

5] Outline of ICD-10-CM                                                                                     

6] Numerical listing of ICD-10-CM 

7] Outline of history of the DSMs

8] Alphabetical listing of DSM-5 with ICD-9-CM and ICD-10-CM codes

9] Changes from DSM-IV-TR to DSM-5

10] DSM-5 disorders that were not in ICD-IV-TR

11] DSM-IV-TR disorders combined in DSM-5

12] Nomenclature changes in DSM-5

13] NIMH Research Domain Criteria [RDoC]

14] Future in psychiatric diagnosing

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February 21

Folks,

Cognitive therapy for PTSD delivered intensively over little more than a week was as effective as cognitive therapy delivered over three months, and both were superior to supportive therapy [this month’s AJP].

Among patients with probably Alzheimer disease and agitation who were receiving psychosocial interventions, the addition of citalopram compared with placebo significantly reduced agitation and caregiver distress [Wednesday’s JAMA].  While the study used 30 mg/day, FDA recommends 20 mg/day be the upper limit for seniors.  

For alcohol abuse/dependence, topiramate for 12 weeks at a maximum dose of 200 milligrams a day, compared very favorable with an inactive placebo in substantially reducing drinking.  Both groups of patients underwent brief counseling to help them reduce their drinking. Only people with a specific genetic makeup, found in 40 percent of European-Americans, benefited from this treatment [AJP, 14 Feb].
In a study to be published in an AJP later this year, after examining 48 studies including 3,295 participants, researchers concluded that cognitive behavioral therapy (CBT), which focused on reducing psychotic symptoms through cognitive restructuring, had a larger effect than other therapies on the psychotic signs of schizophrenia. Within the CBT approaches,  social skills training had the largest effect.

From next month’s Am J Geriatric Psychiatry:

1] The major new condition in DSM-5 is Hoarding Disorder.  A study treating 11 senior hoarders [no placebo comparison] with a combination of cognitive rehabilitation with exposure-based treatment produced significant reductions in hoarding.

2] A telehealth delivery of problem solving techniques in senior citizens with MDD produced improvements in depressive signs as measured by the HAM.

3] Yoga/Tai Chi compared to aerobic exercises in middle-aged and senior citizens found the former produced significantly better mood, mental health, and sleep than did aerobic exercise. 

4] Minocycline, 150 mg/d po, markedly abolished delirium signs in two pts with terminal cancer, one with URI and another with aspiration pneumonia.  Not clear if the results were the impact on the infections, on the inflammatory system, or through suppression of the microglial activation of the brain.  

After 22 sessions of modular cognitive-behavioral therapy, adults with body dysmorphic disorder showed significant improvements in obsessive-compulsive behavior, depression, insight, and level of disability. [February’s Behavior Therapy.] 

Members of racial or ethnic minority groups benefit just as much from psychotherapy as do members of the white majority in Western countries [February’s Psychiatric Services in Advance.]

Articles continue to be published saying that depressed people have low levels of serum vitamin D.  But I have yet to see a controlled study that shows taking vitamin D supplements effectively treats depression.  If you have seen such, please let me know.

A new study finds that D.C. citizens give its highest doctor approval ratings to psychiatrists--the doctors the rest of the nation ranked at the bottom. (Clara Ritger, National Journal)

It would be difficult to name a condition that has as large an impact on more medical conditions than lack of physical exercise, which is a recognized in ICD-9-CM with the code V69.0. V69.0 is related to all the major ones, cardiovascular disorder, cancer, diabetes, depression.  What is missing is a medical term. Overweight has a term, “obesity,” that is quite useful in leading to measuring it [BMI] and what to do about it.  If someone knows of a good term for “lack of physical exercise,” please bring it to my attention.  I worked with a number of possible acronyms, but many already have a meaning in English, another language, or someone’s last name.  So, at the moment, I’ll use “Lacphe,” and in March will post information about Lacphe at RogerPeele.com.
   . 
Speaking of obesity, a recent study found psychiatrists are about in the middle of medical specialties, at 40% obese.  Surgeons have the highest occurrence, dermatologists the least.

Roger

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January 19

Folks,

From this month’s AJP:

1] Relative to managing refractory social anxiety: Adding clonazepam increases the likelihood of response in patients with social anxiety disorder who remain symptomatic after a trial of an SSRI.

2] The belief that clinician can diagnose borderline personality disorder if the clinician has a negative countertransference may not be politically correct, but gets some support in a study that found that: “Clinician treating borderline patients report feeling incompetent or inadequate and experiencing a sense of confusion and frustrations in sessions.” Of the personality disorders, clinicians tend to like the histrionic the most. 

Qigong gets some positive reviews for immediately relieving anxiety among healthy adults and reducing stress among healthy subjects.

If you want to emphasize to the patient and others that his/her lack of exercise is an issue they should address, one could add “V69.0 Lack of Physical Exercise” to the diagnostic list.  [When ICD-10-CM kicks in next October, then “Z72.3 Lack of Physical Exercise.”]

Relative to insurance and out-of-pocket, some advise from Elias Shaya: “The patient has the freedom to do what they wish and to secure their care as they please. If they do not wish to use their insurance, it is totally their choice and we have no control over that anyway. The key is to make sure that there is not any suggestion in our practice that we render different types or processes of care in a way that is dependent on the patients’ way of paying for the care, for what care we provide should be totally and transparently based on the clinical indications. A simple way to assure uniformity is to have all patients complete a “registration form” which typically includes demographics, contact information, and financial responsibility information. If the patient does not include any insurance information on the form, then they are automatically responsible for the payments.
“With regards to giving discounts, or waiving any parts of the fees for any patient with insurance or without insurance, it is critical to have adequate documentation of financial hardship as to the reason for making special arrangements for that specific patient. Otherwise, if we give discounts to everyone or waive co-pays to groups of people (as opposed to specific individuals for specific financial hardship reasons), it could be construed by Medicare and other payers that we inflate our fees for them “fraudulently”, while they are not our ‘real fees’.”

Roger

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January 3

Folks,

Below my name, some reflections on the recent apology for lack of transparency by five researchers associated with DSM-5.

In this month’s AJP:

1] Relative to treating bulimia, two years of psychoanalytic psychotherapy and 5 months of CBT with follow up visits were compared. The proportions of patients who had stopped binging and purging at 2 years were 15% for psychoanalytic psychotherapy and 44% for CBT.

2] SSRIs even as little as 7 days—elevated the risk of upper gastrointestinal bleeding, especially in male patients. 

3] As to social anxiety disorder [SAD], study of patients who had been treated with sertraline and not responded, were placed in three groups:

A] 3.0 mg/day of clonazepam added (sertraline plus clonazepam)

B] a switch to up to 225 mg/day of venlafaxine, or

C] prolonged sertraline treatment with placebo (sertraline plus placebo).

“A]” saw greatest improvement, that is greater decreased SAD scores.

In this month’s Psychiatric Services: Substantial evidence demonstrates the effectiveness of supported employment. Policy makers should consider including it as a covered service.


Sentinel #24 focused on the article in the Atlantic Monthly on phobias including fear of flying.  One reader’s response: “I seriously have considered being knocked unconscious before boarding a plane, to be revived when we land.  Kathryn, New Jersey.

Dinah Miller, Maryland psychiatric leader reports as to Medicare fees:   I'll list both the e-prescriber amount and the discounted amount for those who haven't met the Medicare e-prescribing requirements:

99205: $240.21/ $235.41
99212: $51.18/$50.15
99213: $85.11/ $83.41
90833: $75.43/ $73.92
90836: $95.38/$93.47
90838:$125.99/$123.48

If someone has the fees for Montgomery County, I would like to include them in a future Sentinel.

Roger

Five researchers, including David Kupfer, the Editor of DSM-5, received some publicity late last month with the media noting their apology for not disclosing in an article championing their Computerized Adaptive Test for Depression [CAT-DI], that they plan to market their product. CAT-DI is a bank of 389 items. The initial answers that the person taking the test gives quickly narrows the number of items actually needing to be answered to about twelve -- and takes a little over 2 minutes to complete.  DSM-5 does not call for the use of CAT-DT, it does champion the use of dimensions in the part of DSM-5 that is optional.  The Washington Psychiatric Society [WPS] had successful motions that dimensions only be optional in DSM-5.  [WPS also had the successful motion to remove the Multiaxial System.]  Bottom line: Media hop la was a reflection on an article in a JAMA publication, not a reflection on DSM-5.

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