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.
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.
2] Comprehensive listing of psychiatric conditions including
B] CD-10-CM codes in italics for many disorders
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
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.
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’.”
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:
If someone has the fees for Montgomery County, I would like to include them in a future Sentinel.
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.