Sentinels

 

 
 

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December 14

Folks,
Below my name, terms used relative to reimbursements.

From JAMA, Wednesday:
1] “Flipped classroom,” meaning use of smartphones to study, appears needed for the first two years of medical school.

2] “Flipped patient,” meaning using the smartphone’s data as a source of interaction with the “patient” and making clinical decisions may be attractive to new generations of physicians who may feel texting is more intimate than face-to-face, but a flipped patient may lose the rapport with the practitioner and may be too passive a style to meet the real patient’s needs.

3] Two review articles are not reassuring that the costs, the pain, the time devoted to recertification produce better physicians. [It is unclear, actually, if I follow these articles, that Board certification itself means a better physician. No one in psychiatry has been recertified more than I have (eleven times), and on seeing what the tests consist of, I pay no attention to whether a psychiatrist is certified when making referrals.]

4] We are still graduating less than 1,200 psychiatrists from residencies each year, far short of the need. Breakdown: 7% African-American; 27% Asian; 9% Hispanic; 0.003% Pacific islands; 0.003 American Indian; 66% White or other. [This adds up to >100% because Hispanics can list themselves twice.]Females, 54%. IMGs, 32%.
In JAMA, 26 Nov 2014, an article that describes concerns with muscularity of young males, “but may not be recognized” by practitioners. DSM-5, however, has it recognized: “Body Dysmorphic Disorder, with muscle dysmorphia, 300.7.”
Sometimes you may want to point out that the pt’s loneliness is a factor in selecting group therapy. If so, the entry is “V62.89 Loneliness.”
If you want to sound insufferably sophisticated as to lakphy and depression, can say: “Kynurenine metabolism in skeletal muscle mediated resilience to stress-induced behavior associated with psychiatric illnesses such as major depression” [This week’s NEJM, page 2333.]
Roger
[In Florida]

 

A
Affordable Care Act (ACA) - The health reform law enacted in 2010. (The formal name is the Patient Protection and Affordable Care Act- PPACA.)
Allowable Amount  -The maximum dollar amount that an insurer will consider reimbursing for a covered service or procedure. This dollar amount may not be the amount ultimately paid to the member or provider as it may be reduced by any co-insurance, deductible or amount beyond the annual maximum. Some plans may refer to the "allowable amount" as the "maximum allowable amount"; these terms have a similar meaning.
Allowed Charge  -The maximum amount that an insurer will consider to pay for a service, including any amount that the patient will be responsible for paying. For in-network providers, the allowed charge is based on the contracts with the providers. For out-of-network providers, the allowed charges may be:

  • the same as for in-network providers,
  • based on a percentage of the amount that Medicare would pay for the same services, or
  • Usual, Customary and Reasonable (UCR) charges, an amount that your plan determines is reasonable for that service in your local area.

Approval Number  -A number issued by your insurer authorizing the health insurance company to pay for your care. You may need to obtain an approval number from your insurer before you see a particular doctor or receive a particular medical service in order for your health insurance company to pay for that visit and/or service. Your doctor’s office staff might be able to help you obtain the approval number from your insurer.


B
Balance Billing  -Balance billing is a type of healthcare billing that occurs when an out-of-network provider bills a plan member for the difference between the out-of-network provider's charge and the amount paid by a member's benefit plan for the out-of-network service, and this difference exceeds the member’s defined liability from the Plan. This means that if the defined out-of-pocket for the member was 20% of the provider’s charge and the member pays more than 20% - not due to a deductible application – this is a balance bill. This situation happens when a provider does not participate in a member's provider network.
Billed Charge  -The amount billed by your physician or other healthcare provider for services you have received. If you use a provider in your plan’s network, the billed charge usually is submitted directly to the insurer and is reduced by the claim payment system to the allowed amount, or contracted rate negotiated by your insurer and its network provider. But, if you use providers outside your network, you will generally have to pay the full difference between your insurer’s allowed amount and the amount that your provider charges that exceeds the allowed amount unless you and your provider agree otherwise.


C
CDT or Current Dental Terminology  - Current Dental Terminology (CDT) codes are numbers assigned to dental services and procedures. These codes help support accurate recording and reporting of dental treatment and are part of a uniform system designed and maintained by the American Dental Association (ADA). CDT codes have a consistent format and each is unique. Every code number has a written description of the specific dental service or procedure. You will see CDT code(s) on your Explanation of Benefits form (EOB), or you can ask your dental provider for the CDT code for a procedure or service you will undergo, or have already received.
Co-insurance  -Co-insurance is a cost sharing feature of many plans. It requires a member to pay out-of-pocket a prescribed portion of the cost of covered healthcare expenses. The defined co-insurance that a member must pay out-of-pocket is based upon his or her health plan design. Co-insurance is established as a predetermined percentage of the allowed amount for covered services and usually applies after a deductible is met in a deductible plan, such as deductible HMO, preferred provider organization (PPO), point-of-service (POS), and indemnity plans.
Co-payment or "Co-pay"  - A form of medical cost sharing in a health insurance plan that requires the member to pay a fixed dollar amount for each visit to a doctor or for a specific service. This fee is pre-set; it will be specified in your health insurance policy and also may be listed on your insurance card.
Commercial Health and Dental Insurance Data  - Commercial health and dental insurance data, which are the type in the FAIR Health Database, are based on charge amounts billed by healthcare providers, as reported by health plans and other healthcare payors in the private insurance system. FAIR Health uses these data to develop medical and dental cost estimates that reflect the fees that healthcare providers bill in different geographic areas. These fees are similar to what health insurance plans may call “usual, customary and reasonable” (UCR) charges. Cost estimates based on FAIR Health data are different from fees established by Medicare, a federal health insurance program that covers individuals ages 65 and older, as well as individuals with end-stage renal disease and certain persons with disabilities. Medicare fees are usually lower than commercial charge amounts.
The FH Medical Cost Lookup provides out-of-pocket cost estimates for individuals covered by plans that use either UCR-based or Medicare-based out-of-network reimbursement methods. Also see Medicare. The data available on the FH Consumer Cost Lookup reflect fees for services provided“out-of-network,” and not the “in-network” fees negotiated by insurers for services obtained from providers who participate in the plan’s network.
Contracted Rates  -The amounts that health insurance companies will pay to healthcare providers in their networks for services. These rates are negotiated and established in the insurers’ contracts with in-network providers.
Coordination of Benefits  - The process of reconciling healthcare charges when an individual is covered by more than one health insurance plan or policy. For example, if a child is insured through both parents’ employers’ plans, one insurer is generally considered the primary insurer and pays first, and the insurer considered secondary reimburses after the primary plan pays. The secondary insurer’s reimbursement, if any, takes into consideration any outstanding dollar amounts for covered services received up to the allowed amount. In any case, the secondary plan will never pay more than they would have paid had they been primary.
Cost-sharing  -A requirement that insured patients pay a portion of their medical costs, either as a deductible, or a flat dollar co-payment, or as co-insurance (i.e., a percentage of the total paid claim for a covered benefit or service).
Covered Services  -The medical services, procedures, prescription drugs and other healthcare services that your insurer pays for under your plan. Keep in mind that not all care is covered. For instance, some plans will not pay for medications that are available over the counter. And, even if a service is covered, you may still need to pay a co-payment or co-insurance, request pre-authorization, or get a referral from your primary care physician before your insurer will pay. Your policy should contain a detailed list of what is and is not covered.
CPT Modifier  -A code that is used to provide additional information on a procedure or service. For example, there are modifiers that indicate that a procedure is being repeated or that multiple surgeries were performed at the same time. They can also indicate that the service is more or less complex than normal. The modifier can affect how much the plan will pay the provider.
CPT® or Current Procedural Terminology® - CPT® is a registered trademark of the American Medical Association (“AMA”). Current Procedural Terminology (CPT) codes are numbers assigned to services and procedures performed for patients by medical practitioners. The codes are part of a uniform system maintained by the American Medical Association (AMA) and used by medical providers, facilities and insurers. Each code number is unique and refers to a written description of a specific medical service or procedure. CPT codes are often used on medical bills to identify the charge for each service and procedure billed by a provider to you and/or your insurer. Most CPT codes are very specific in nature. For example, the CPT code for a fifteen-minute office visit is different from the CPT code for a thirty-minute office visit.
You will see a CPT code on your Explanation of Benefits form (EOB). You can also ask your healthcare provider for the CPT code for a procedure or service you will undergo, or have already received.


D
Deductible  -A fixed dollar amount of healthcare costs that you must pay before your insurer will consider payment for a healthcare service you receive. In most cases, you must pay the deductible amount each calendar/plan year. Many insurance plans have both per individual and per family deductibles. The per family deductible helps to limit the number of deductibles a family will pay in order to have all covered members of the family eligible for claim payments.
Department of Health and Human Services  -The federal cabinet-level agency that administers federal health, welfare, and human services programs and activities. HHS has lead agency responsibility for significant aspects of the Patient Protection and Affordable Care Act and is home to the Centers for Medicare and Medicaid Services and its Center for Medicare and Medicaid Innovation, the Health Resources and Services Administration, the Centers for Disease Control and Prevention, the Agency for Health Care Research and Quality, the National Institutes of Health, the HHS Inspector General, the HHS Office for Civil Rights, the HHS Office of Minority Health, the Substance Abuse and Mental Health Services Administration, the Indian Health Service, and other federal agencies that oversee the Patient Protection and Affordable Care Act.


E
Electrical Stimulation-  Electrical stimulators and supplies are used for managing pain and wound healing.
Emergency Medical Treatment and Active Labor Act (EMTALA) -is a U.S. Act of Congress passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA). It requires hospitals and ambulance services to provide care to anyone needing emergency healthcare treatment regardless of citizenship, legal status or ability to pay. There are no reimbursement provisions. As a result of the act, patients needing emergency treatment can be discharged only under their own informed consent or when their condition requires transfer to a hospital better equipped to administer the treatment.
Exchanges  -State health insurance “marketplaces” whose establishment was mandated by the Patient Protection and Affordable Care Act. Exchanges are to be established by 2014 for individuals and small employer groups (exchanges for small employers are known as SHOP exchanges). Exchanges are responsible for calculating premium subsidies, enrollment, quality oversight, certification of qualified health plans that can be sold in the exchange, and other matters. By standardizing health insurance products, enrollment, operations, and oversight, exchanges are also meant to make the process of selecting insurance easier and transparent.
Exclusive Provider Organization (EPO) -A managed care organization that exhibits characteristics of both health maintenance organizations (HMOs) and preferred provider organizations (PPOs). Like an HMO, an EPO plan requires that members visit in-network providers only; care from out-of-network providers is not covered except in some cases for an emergency. Like a PPO, an EPO plan often allows members to see specialists without first obtaining a referral from a primary care doctor; these specialist visits are covered as long as the providers are in the network.
Explanation of Benefits (EOB) -Your insurer will provide you with an EOB after you have submitted a healthcare claim to your insurer or after a provider has submitted a claim to your insurer on your behalf. The EOB will include a detailed explanation of how your insurer/administrator determined the amount of reimbursement it made to your provider or to you for a particular medical service. The EOB will also include information on how to appeal or challenge your insurer’s reimbursement decision. Note that you may not receive an EOB for care that you have received from a provider or facility that is in your insurer’s network if there is no required payment from you for those services.


G
Geozip  -A geographic area that is defined by the first three digits of a zip code. For example, the geozip for zip code 13202 is 132.


H
Health Insurance Portability and Accountability Act (HIPAA) -A federal law that protects the privacy of individuals’ health information, regulates health insurance portability and non-discrimination, and provides health insurance simplification. The HIPAA provisions have been broadly expanded by the Patient Protection and Affordable Care Act.
Health Maintenance Organization (HMO) -An HMO is a health plan that typically has a closed network of physicians and other healthcare providers, and hospitals. With a traditional HMO plan, a member receives services from the HMO's providers for a predetermined co-payment. A member pays only co-payments for services and need not file claim forms unless he or she receives medical services outside the network. Non-emergency services received outside the network without prior plan approval are not covered by the plan.
Health Savings Account (HSA) -An HSA is a tax-advantaged savings account that a member can open to pay for qualified medical expenses. Contributions to an HSA can be made by both a member and his or her employer, but the money belongs to the member. The money invested in an HSA is tax-deductible, and any earnings are tax-deferred. The member can withdraw funds tax-free and without penalty from the account if the funds are used to pay for qualified medical expenses. The HSA is portable and goes with the member if the member changes jobs. Tax references are applicable per federal tax regulations. State tax regulations may vary. (See the page about HSAs at the U.S. Department of the Treasury Web site.) (See the Internal Revenue Service's list of qualified medical and dental expenses.)
Healthcare Common Procedure Coding System (HCPCS) codes  -There are two main types of HCPCS codes: Level I and Level II codes.
Level I codes are 5-character Current Procedural Terminology (CPT) Codes that are developed and maintained by the American Medical Association. CPT codes refer to professional services such as reading an MRI, giving a shot, seeing a patient for an office visit or performing surgery. There are 3 categories of Level I codes. Category I codes have 5 digits. Category II codes are used for performance measurement and have 4 digits followed by the letter F. Category III codes are used for emerging technologies, and have 4 digits followed by the letter T.
Level II HCPCS codes include one letter followed by 4 digits (e.g., A9999). Most Level II codes refer to services or items such as durable medical equipment (e.g., wheelchairs, crutches), ambulance services, vision and hearing supplies, injectable and chemotherapy drugs and prosthetic devices. Level II HCPCS codes are maintained by the Centers for Medicare and Medicaid Services (CMS), a division of the US Department of Health and Human Services. You may see a HCPCS code on your Explanation of Benefits form (EOB). You can also ask your healthcare provider for the relevant HCPCS code(s) for a procedure or service you will undergo, or have already received.
Healthcare Professional  -A physician, dentist, nurse, physician assistant, or any other individual who is licensed or certified as required in his or her state and is performing services within the scope of that license or certification.
Healthcare.gov  -A website maintained by the Office of Consumer Information and Insurance Oversight of the Department of Health and Human Services that provides information to consumers on available insurance options, data on care quality, and resources for disease prevention.
HHS  -See Department of Health and Human Services.
HIPAA  -See Health Insurance Portability and Accountability Act.


I
Incontinences/Ostomy Supplies-Incontinence and ostomy supplies are medical devices that are used for collecting urine and waste materials.
In-Network  -Pertains to treatment from doctors, clinics, health centers, hospitals, medical practices and other providers with whom your plan has an agreement to provide care for its members. Usually, you will pay less out of your own pocket when you receive treatment from in-network providers.
Institutional Review Board (IRB) -A group of people appointed by an institution (such as a hospital or university) to review and monitor research projects involving human subjects, with the purpose of protecting the rights and welfare of the people who are participating as subjects in the research. An IRB seeks to ensure that subjects are not placed at undue risk, and that they give uncoerced, informed consent to their participation. To this end, an IRB has the authority to approve, disapprove, and require modifications to research projects involving human subjects. Once a project is approved, the IRB must monitor the progress of the ongoing research, prospectively approve modifications, and suspend the project if necessary to protect subjects.
Maximum Allowable Amount -The maximum dollar amount that an insurer will consider reimbursing for a covered service or procedure. This dollar amount may not be the amount ultimately paid to the member or provider as it may be reduced by any co-insurance, deductible or amount beyond the annual maximum. Some plans may refer to the "allowable amount" as the "maximum allowable amount"; these terms have a similar meaning.
Medicare  -The federal health insurance program for individuals ages 65 and older, as well as persons with end-stage renal disease and certain persons with disabilities. Medicare covers beneficiaries for hospital, post-hospital extended care, and home healthcare, as well as a range of medical care services and benefits. Medicare enrollment is compulsory for all individuals covered by the Social Security Act. At their option, Medicare beneficiaries can buy “Part D”outpatient prescription drug coverage. Beneficiaries can elect to enroll either in “traditional” Medicare (which allows patients to receive care from any participating physician, hospital or healthcare supplier) or through Medicare Advantage Plans, most of which restrict patients to specific network providers while typically offering additional benefits and coverage. The Patient Protection and Affordable Care Act expands Medicare coverage for preventative services and additional levels of prescription drug coverage while also introducing reforms to improve healthcare quality and efficiency.


N
Non-covered charges  - Costs for medical treatment that your insurer does not cover. In some cases the service is a covered service, but the insurer’s reimbursement does not cover the entire charge amount. In these cases, you will be responsible for any charge not covered by your plan. In some cases the service itself is not covered by your plan and you will be responsible for the full charge. You may wish to call your insurer or consult your health insurance policy to determine whether certain services are included in your plan before you receive those services from your doctor.
Non-Covered Services  - Medical services that are not included in your plan. If you receive non-covered services, your health plan will not reimburse for those services and your provider will bill you, and you will be responsible for the full cost. You will need to consult with your health insurer, but generally payments you make for these services do not count toward your deductible. Make sure you know what services are covered before you visit your doctor.


O
Orthotic Devices - Orthotics are medical devices that are used for treatment of the neuromuscular and skeletal system.
Out-of-Network  -Pertains to treatment from doctors, clinics, health centers, hospitals, medical practices and other providers that do not have an agreement with your health insurer to provide care to its members. You typically will pay more out of your own pocket when you receive treatment from out-of-network providers.
Out-of-network benefits -Benefit plan coverage for services provided by doctors and other healthcare professionals who are not under a contract with your health plan.
Out-of-pocket cost  - Portion of the cost of healthcare services that the plan member must pay. This cost includes the difference between the amount charged by an out-of-network provider and what a health plan reimburses for such services.
Out-of-Pocket Maximum  - The limit on the total amount a health insurance company requires a member to pay in deductible and co-insurance in a year. After reaching an out-of-pocket maximum, a member no longer pays co-insurance because the plan will begin to pay 100% of medical expenses. This only applies to covered services. Members are still responsible for services that are not covered by the plan even if they have reached the out-of-pocked maximum for covered expenses. Members also continue to pay their monthly premiums to maintain their health insurance policies.


P
Participating Provider  - A physician, dentist or other healthcare professional, hospital or healthcare facility that contracts with your health insurer to provide services to its members at a specific fee amount.
Patient Protection and Affordable Care Act  -The formal name of the health reform law enacted in 2010.
Percentile  -A statistical measure used to describe how a particular quantity (such as the cost of a specific healthcare procedure) varies across a range of sources (such as all the doctors in your area.) For example, 50% of all fees billed by providers are at or below the level indicated by the 50th percentile; 80% of all fees billed by providers are at or below the level indicated by the 80th percentile. Percentiles are important because they are used by many insurers in determining the highest level of a billed charge that they will consider for reimbursement.
Physician  -An individual who has received a “Doctor of Medicine” (MD) or Doctor of Osteopathic Medicine (DO) degree and is licensed to practice medicine in their state.
Point of Service (POS) Plan -A health plan that allows you to choose at the time medical services are to be received whether you will go to a provider within your plan’s network or seek care outside the network.
Pre-existing condition  - A health condition that exists for a set time prior to enrollment into a health plan, regardless of whether the condition has been formally diagnosed. The Patient Protection and Affordable Care Act prohibits insurers and employer-sponsored health plans from denying or limiting coverage to individuals with pre-existing health conditions.
Preauthorization  -A process that your health plan or insurer goes through to make a decision that particular healthcare services, treatment plans, prescription drugs or durable medical equipment prescribed by your doctor are covered and medically necessary. Your plan may require preauthorization for certain services, such as hospitalization, before you receive them. Preauthorization requirements are generally waived if you need emergency care.
Preferred Provider Organization (PPO) -A health plan that is designed to encourage you to receive your healthcare through a network of selected healthcare providers (such as hospitals and physicians). If your plan is a PPO, your medical expenses will be lower if you use a provider or facility that is part of your plan’s network. You are entitled to receive reimbursement for care from providers and facilities that are outside the network, but you may pay a larger portion of the charges for such "out-of-network" care.
Premium  -The amount a consumer (or employer) pays to a health insurance company for health coverage. The health insurance company generally recalculates the premium each policy year. This amount is usually paid in monthly installments. When a consumer receives health insurance through an employer, the employer generally pays a portion of the cost of the premium and the consumer pays the rest, often through regular payroll deductions.
Primary Care Physician (PCP) - A family doctor, internist or pediatrician who coordinates your care or your family’s care. Some types of plans, like a POS or HMO, require that you visit your PCP first for any care that you need. But even if you’re not required to use a PCP, it’s a good idea to develop a relationship with a primary care doctor who knows your medical history and can make sure you’re getting the care you need.
Provider  -A doctor or other healthcare professional, hospital or healthcare facility that is accredited, licensed or certified to practice in their state, and is providing services within the scope of that accreditation, license or certification. Washington Psychiatric Society suggests that one use "Practitioner," not "provider."
Provider network  - Doctors and other healthcare professionals who agree to provide medical care to members of a health plan, under the terms of a contract.
Prudent Layperson Standard  - Under PPACA, a condition with acute symptoms of sufficient severity (including severe pain) that a person who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in—(i) placing the health of the individual (or an unborn child) in serious jeopardy, (ii) serious impairment of bodily functions, or (iii) serious dysfunction of any bodily organ or part.


Q
Qualified Medical Expenses  - Qualified medical expenses are defined under Section 213 of the Internal Revenue Code. (See the Internal Revenue Service's Publication 502 about medical and dental expenses.) Qualified medical expenses and other expenses permitted to be reimbursed from health savings accounts (HSAs) include, but are not limited to, the following:

  • doctors' visits
  • ambulance and hospital services
  • prescription drugs and certain over-the-counter prescription medications
  • durable medical equipment
  • dental care
  • acupuncture
  • chiropractic services
  • COBRA healthcare continuation coverage
  • qualified long-term care services and limited long-term care premiums
  • vision care
  • health insurance premiums for individuals receiving unemployment compensation
  • at age 65 and over, Medicare Part A and B, Medicare HMO, and a member's share of employer-sponsored health insurance premiums (but not Medicare Supplement premiums)

A medical expense is not a qualified expense if a member receives reimbursement for it under insurance coverage. If the member's expense is paid for or reimbursed by an HSA account, that expense cannot be included for purposes of determining itemized tax deductions.


R
Reimbursement  - The amount that your insurer pays for a specific service. For instance, your insurer’s reimbursement rate for a primary care visit may be up to $80. If your provider charges $100, you would be responsible for the remaining $20 if your plan covers that service at 100% of the maximum fee.
Respirator and Oxygen Equipment  - Respirator and oxygen equipment are used by people who have difficulty breathing.


S
Self-Insured  - If you work for a large employer or group of employers, your plan may be self-insured. Self- insured means that your employer pays medical claims from their bank account and establishes the plan design. The benefits may be administered from a third-party administrator (“TPA”) or a Health Plan. Self- insured plans are not under the control of the Department of Insurance and the employer bears the cost for all utilization.
Sleep Apnea Devices - Sleep apnea devices are used to increase airflow to the lungs.


U
Upstate Health Research Network (UHRN) - The Upstate Health Research Network is a team of researchers comprised of health policy experts, statisticians, economists, and healthcare professionals from New York State and across the country which was tasked with assisting FAIR Health enhance and refine the methodologies and processes underlying its comprehensive database of healthcare claims. The UHRN is led by Syracuse University and includes researchers from Cornell University, University of Rochester, University at Albany (SUNY), University at Buffalo (SUNY), and SUNY Upstate. The University of Illinois, Indiana University, University of Colorado Denver and Arizona State University joined the UHRN as adjunct research institutions.
Usual and Customary Rate (UCR) - A term often used to describe a level of reimbursement that insurers use to calculate reimbursements for out-of-network care. If your plan covers some out-of-network care, your insurer may base the payment on a price that it determines to be “usual, customary and reasonable” in your area. It’s a good idea to find out this rate and then ask your provider how much he or she will charge for the service you need. To understand your plan’s UCR, contact your insurer. That way, you can make an informed decision and you won’t be surprised by a large bill.

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November 30

Folks,

Cartoon, “I had to stop watching the news – it was making my own problems seem insignificant.”  [The New Yorker, 10 Nov 2014.]

About 35 years ago, Richard Jed Wyatt [St Es] wrote for SCIENCE an editorial pointing out that developments in science are based on controlled experiments, but that is not required in the implementation of health care policy.

JAMA, 26 Nov 2014, has some major articles on health care policy: There is an excellent review of US Health Care blame game (Ending the Cycle of Blame in US Health Care) but the solution suggested at the end of the article is not empirical studies, but “multi-stakeholder discussions and a focus on consensus-based policy solutions.”

Returning to our interest in lakphy, 74 trials of 12 antidepressants involving 12,564 pts found only 51% showed a positive benefit for antidepressants over placebo, and letters to the JAMA editor suggested that exercise may be doing better than 51%, but the letters are not clear as to the percentage to apply to exercise [JAMA 26 Nov 2014].

Taking folic acid and vitamin B12 supplements “may NOT reduce the risk of memory and thinking problems.” [Neurology 12 Nov 2014.]

DSM-5 will not be recalled, so we have to make the repairs ourselves:

1] Page 42, Language Disorder, change ICD-9-CM code from 315.39 to 315.32

2] Page 195, Selective Mutism, change ICD-9-CM code from 313.23 to 312.23

3] Page 362, Insomnia Disorder, change ICD-9-CM code from 780.52 to 307.42.

4] Page 368, Hypersomnolence Disorder, change ICM-9-CM code from 780.54 to 307.44.

5] Page 705, Zoophilia is Not 302.89, but 302.1.

6] Page 798, change “Neurobehavioral” to “Neurodevelopmental.”

Please bring other errors to my attention.

Roger

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November 24

Folks,

In my experience, no politician respected Saint Es more than Marion Barry.  In 1994, he held the first cabinet meeting of his fourth term at Saint Es.  His smarts were impressive.  Even if it was years between one meeting with him and another, he could always recall the last thing we talked about.

The number of psychiatric residencies in this country has remained fixed since 1997 and seems unlikely to change in the near future. [The Atlantic, Nov 2014]

Using modafinil or armodafinil to reverse the deficit [“negative”] signs of schizophrenia does not benefit or worsen other symptom dimensions in schizophrenia. [J Psychiatric Research 11/17/2014]

For treatment-resistance bipolar disorder, the limited evidence supports the concept that clozapine may be both effective and relatively safe. [Bipolar Disorder, 11/19/2014]

Comparing medication-induced sexual dysfunction of flouoxetine, sertraline and trazodone found fluoxetine the most, trazodone the least. [Gen Hosp Psychiatry 11/19/2014]

Telephone cognitive-behavioral therapy for adolescents with OCD concluded that it is NOT inferior to standard clinic-based CBT. [J AACAP, 11/19/2014]

As to whether the AMA will again go to Congress and try to have ICD-10-CM posted again, early this month, the AMA President said, “For more than a decade, the AMA kept ICD-10 at bay...and we want to freeze it in carbonite.”

Over a six-year period, giving omega-3 supplements to patients at high risk of psychosis for up to a median of 6.7 years after the original intervention, just four (9.8%) of 41 patients in the omega-3 group had transitioned to psychosis, compared with 16 (40.0%) of 40 patients given placebo.” [International Early Psychosis Conference, November 2014].

As to art therapy with children, typical art therapeutic elements such as sensory experiences with sight and touch may improve social behavior, flexibility and attention–abilities of autistic children. [The Arts in Psychotherapy, 11/19/2014]  

We want to wish all a fulfilling Thanksgiving.

Roger

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November 6

Folks,

Two experts were asked, is suicide predictable?  Answer, “no,” except in the immediate situation.  [AAPL Newsletter, Sep 2014.]

Amer J of Geriatric Psychiatry, Nov 2014:

1] Per our interest in lakphy, physical activity in women > 85 y/o was associated with lower incidence of dementia.

2] Elderly lithium users have relatively higher rates of chronic kidney disease.

3] Keeping in mind that we have yet to prove we know how to prevent suicides, an article suggests that in men >75 years old addressing loneliness might prevent suicides.

Yesterday’s meeting of the local Child and Adolescent association found the talk relying less on published results and more on results that can be found at NIH’s ClinicalTrials.gov.  I gather this will become more common in psychiatric presentations as currency is desired.

As to differentiating bipolar and ADHD in children, an episodic history may point to bipolar, but we need to remember that the kid may have both.  If both, Robert Post recommends that one first stabilize the mood in pediatric bipolar and then secondarily treat the reside\dual [persistent] ADHD symptoms with low-dose stimulants [Psychiatric Annals, Sep 2014].

Types of psychotherapy that are most effective at reducing symptoms of bipolar disorder in adolescents and young adults: interpersonal and social rhythm therapy and specialist supportive care [Bipolar Disorders, October, 2014]

A review of on the tenth anniversary of the FDA’s black-box warning for antidepressants noted that it resulted from 100,000 sample that showed a 4% rate of suicidal thoughts or behaviors [no suicides] and a 2% rate among those taking placebos. Risk higher among those less than 25 y/o.  On the other hand, patients 65 years old had less suicidal ideation and behavior, which the black-box seemed to be harmful for that age group.  An editorial suggests that the FDA remove black-box expectations. [NEJM, 30 Oct 2014.]

From this month’s AJP:

1] Meds for Borderline Syndrome:

Positive trial:
       Aripiprazole
       Lamotrigine
       Quetiapine, doses
       Topiramate [150 mg/d but not impressive at 300 mg/d]
       Valproate
      
Negative trials:
       Fluoxetine
       Fluvoxamine
       Mianserin
       Phenelzine
Ziprasidone    

Mixed results:
       Olanzapine

Meds do not seem to reach the Borderline symptom of “feelings of emptiness,” which is better addressed with psychotherapy.  More generally, I suspect the APA Practice Guideline on Borderline Syndrome, 2001, conclusion that psychotherapy is the preferred treatment for Borderline still stands. Too often, it has been suggested, some clinicians in other parts of the country diagnose these people as “Borderline II” to avoid the psychotherapy expectation.

2] Supportive employments positive results have been associated with studies lasting two years.  Now a study that shows the result are quite positive after five years.

3] A study of male smokers found that those who did not show a sufficient response to prequit nicotine patch treatment, did benefit by adding varenicline and bupropion, but adding only varenicline was not efficacious.

Roger 

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October 31

Folks,

Below my name are some thoughts as to why psychiatry has been stuck for half a century.

Periodically I suffer from Know-It-All Disorder.  Over the years, I have found that no one cures it faster than Bill Lawson.  When Bill saw my complete list of Lakphy, he added four: Lack of social relations; being accused of being a 90 pound weakling; Constipation; Various skin disorders including bed sores.

Amer J on Addictions, Nov-Dec, 1014:

1. A new abuse is being reported in NYC: antiviral medication abuse, meds used alone or another abuse substance].  The article suggests that these meds have a stimulant quality, but maybe the attraction will be just “to feel different.” Best code: 305.9x antiviral medication abuse [for x, 1 = continuous; 2 = episodic, 3 = in remission, 0 = unspecified].

2. Injectable extended-release naltrexone did NOT result any measurable reduction in cocaine or alcohol use over the course of 8 weeks of treatment.

October 21’s NY Times made a strong case for lifestyle changes that would lead to adequate sleep in adolescents. If you think it helps to emphasize with a patient that lack of sleep is a medical condition, you can provide a medical code for such, V-69.4, sleep deprivation.

Our October 10 Sentinel spoke of the potential advantages of the massive electronic medical data.  NY Times of October 14 had an article that took a different view: Medical information in digital piles is becoming gigantic, unwieldy and unreadable. The article also warned of the dangers that physicians will limit their interactions with patients because of the availability of check-list information, might lead some to avoid important explorations, concluding: “Good medicine depends on deliberate, inefficient, plodding, expensive repetition. No system of data management will ever replace it.” Note “inefficient” and “expensive” tied to good medicine.

As to OCD, CBT remains the treatment of choice, and yet only 10% receive such.  As to medications, about a third receives adequate treatment, e.g., clomipramine or SSRIs [NY Times, 14 Oct 2014]. 

On October 9, about 500 people showed up at the Sidwell Friends School's auditorium to hear Atul Gawande talk about his new book, BEING MORTAL: MEDICINE AND WHAT MATTERS IN THE END, which appears headed for the top of the nonfiction best-sellers list.  His messages are less jarring to psychiatrists than some other parts of medicine:  Physicians need to focus on the quality of life, not the length, especially when dealing with cancer patients.  In dealing with these issues, something is amiss if the physician-patient session has time limits, or finds that the physician is talking more than the patient.      

Roger

By 1964, we had:

1] AD/HD: amphetamines [1934]

2] Alcohol abstinence: disulfiram [1930s]

3] Alcohol withdrawal: chlordiazepoxide [1961]

4] Antipsychotics: Chlorpromazine [1952]

5] Antidepressant: Imipramine and ECT [1936]

6] Anxiolytics: Chlordiazepoxide [1961]

7] Catatonia: ECT [1936] and chlordiazepoxide [1961]

8] Mood stabilizers: Lithium [1947]

9] Narcolepsy: amphetamine [1934]

10] Obsessive-compulsive disorder: clomipramine [1962]

11] Panic attack: phenelzine: [1959]

12] Porphyria: chlorpromazine [1952]

13] Sedatives: barbital [1904]

We had two very broad effective psychotherapies:

1] Psychodynamic [1896?]

2] Cognitive behavioral therapy [1924/1937/1963]

Have we had any major new medication categories over the last half century? We have:

1] Some meds to postpone Alzheimer’s a few months

2] Fluoxetine for bulimia,

3] Doxepin and pregabalin for fibromyalgia,

4] Buprenorphine and naltrexone for opioid addiction,

5] A bunch for erectile dysfunction.

In addition to these five advances, up to two dozen meds have been developed in each of the categories listed above.  The justification for marketing the newer meds is usually tied to individualized different reactions in patients as to efficaciousness and side effects.  We’ve all seen these individualized reactions that were a miracle for a particular patient.  Moreover, a few of the newer meds do seem more efficacious that the breakthrough medication, e.g., clozapine [1971].

Is psychiatry stuck as to finding the really new as to etiology and as to treatment?  Fifty years is a long time, especially given the thirty-fold or so increase in our neuroscience knowledge since 1964.

Two NIMH Directors and others have suggested that the basic reason we are stuck is our division of psychopathology, the DSMs.  The DSMs are consensus-based, not science-based.  Maybe we can’t build a science of psychiatric treatments using the DSMs as the foundation?

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October 24

Folks,
Below my name, a list of conditions associated with lakphy [lack of physical exercise].  A somewhat similar list exists with “obesity.”  As we gain experience with lorcaserian [Belviq] and similar anti-obesity meds, it should become clearer as to which is more lethal, obesity or lakphy.

Lakphy is a side effect of statins and may contribute to a mental decline [Caring for the Ages, October].
When prescribing antidepressants consider asking the pt to eat fatty fish [salmon or sardines] at least once a week as a study has suggested that people with MDD who ate fatty fish at least once a week had a 75% increased chance of antidepressant response vs a 23% response rate for those who never ate fatty fish. [27th European College of Neuropsychopharmacology (ECNP) Congress. Abstract P.2.b.031. Presented October 20, 2014.]

As to augmenting SRI treatment with topiramate, average dose, 138 mg/d, for pts with OCD, a study did NOT find this augmentation helped. Journal of Research in Medical Sciences, 10/23/2014  
The preferred treatment of catatonia remains the same as it has been for half a century: benzodiazepines or ECT. (Journal of Psychiatric Research, 09/18/2014)  

Using the amino acid l-lysine for patients with chronic schizophrenia as an adjunctive to risperidone during an 8–week trial got positive results as to tolerability and efficaciousness as to improving negative and general psychopathology symptoms. The safety and efficacy of higher doses of l–lysine and longer treatment periods remain unknown. (Journal of Psychiatric Research, 09/18/2014)

A meta-analysis concluded that combining psychotherapy with antidepressants is more effective than treatment with antidepressant medication alone in major depression, panic disorder, and OCD. These effects remain strong and significant up to two years after treatment. (Focus, 26 Aug 2014)

In this month’s AJP:

1] For social anxiety disorder, psychodynamic therapy and CBT were equally effective.
  
2] Never use antidepressants alone with bipolar patients. Use with Lithium, valproate, or lamotrigine to reduce chance of a manic episode. Patients with a depression-predominant polarity, with bipolar II disorder, or with a previous response to anti-depressant may be a candidate for an adjunctive anti-depressant.

3] In treating claustrophobia with exposure therapy, providing methyl blue, 260 mg, immediately following the extinction trial, led to retention of fear extinction in comparison to placebo.  This approach may have deleterious effect on extinction when administered after an unsuccessful exposure session. 
When presented with a patient dementia, a message from Mayo clinic this month reminds us to be sure to rule out very treatable conditions:

1] Depression
2] Anxiety
3] Alcoholism
4] Hypothyroidism
5] Vitamin deficiencies.
6] Sleep apnea
7] Head injuries with a subdural
8] Hydrocephalus
9] Delirium
10] Medications: sleeping pills, medications for nausea and urinary incontinence, older antihistamines like Benadryl

Roger

Lakphy [lack of physical exercise] is associated with:

1] Anxiety

2] Cancer

3] Depression

4] Diabetes, type 2

5] Gallstones

6] Heart disease

7] High levels of LDL

8] High levels of triglycerides

9] Hypertension

10] Insomnia

11] Low levels HDL

12] Menstrual issues and infertility

13] Memory loss

14] Metabolic syndrome

15] Muscle atrophy

16] Obesity

17] Osteoporosis

18] Strokes

PLEASE LET ME KNOW OF OTHER DISORDERS ASSOCIATED WITH LAKPHY.

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October 10

Folks,
Below my name, some thoughts from the 3rd Annual Biomedical Information Symposium, 2 Oct 2014.

Phyllis A. Appel, MD, St Es’s trained, very popular with her patients and with her peers, died last Saturday, age 75.  Memorial contributions may be made to the Jewish Social Service Agency, 200 Wood Hill Road, Rockville, MD 20850.

Relative to addressing Ebola issues, daily CDC updates are available here: www.cdc.gov/vhf/ebola/index.html.

Family-based therapy may be the best, and most cost-effective, treatment for teens struggling with anorexia nervosa [JAMA Psychiatry, 24 Sep 2014]

A study with an N of 13,000, concluded CBT is more effective than meds for social anxiety disorder - and it has fewer side effects and may be more cost-effective over the long run [Lancet, Psychiatry, 26 Sep 2014]. For those in settings without CBT, important to know that SSRIs and SNRIs were superior to placebos.

Study suggesting dementia could be prevented or postponed, a shotgun approach with 10 pts, saw improvement in 9 pts involved diet, exercise, supplements, and stress reduction [Aging, 27 Sep 2014].  Impressive results, but unclear what to replicate. Details at:
http://www.medscape.com/viewarticle/832752.

Per our interest in lakphy [lack of physical exercise], moderate to vigorous physical exercise may increase children's cognitive performance and brain function, [Pediatrics, 29 Sep 2014]. Study was two-hour after-school exercise program with 7-9 year olds. 

A single, brief session of resistance exercise done immediately after a visual learning task enhances episodic memory by about 10% 48 hours later compared to controls not doing the resistance exercise [Acta Psychologica, Oct 2014].

In Wednesday’s JAMA, comparing paliperidone palmitrate and haloperidol decanoate found no differences in effectiveness, and found weight gain more prominent in paliperidone pamitrate and akathisia more prominent in haloperidol decanoate.

The pioneer in using data to make clinical decision, Morris Collen, died last month, age 100.  His answer as to how he reached 100 reminds us of our interests in lakphy:  While at work, at his desk, he had an alarm clock that would let him know he had been setting for an hour, where upon he would get up and take a walk.

Roger

Last Thursday, at the 3rd Annual Biomedical Informatics Symposium, the focus was how to trawl through 300,000,000,000,000 points of data and reach diagnostic, therapeutic, and insights into disease.  Last Sunday’s Post had an article demonstrating how trawling data [TD] could benefit a patient with lupus.  Rather than spending billions on double-blind studies, can medicine make more rapid progress and do so at far less cost with TD?

Two NIMH directors and other critics have blamed the lack of progress in psychiatry on the DSMs, that the six DSMs failed to divide psychopathology in ways that capture the developments in science.  Not clear, however, that the critics have a solution.  NIMH’s RDoC. for example, may come up empty handed.

For those of you working in Montgomery County’s Primary Care Clinics [PCC], there is potential for TD.  PCC’s EMR is tied to Medstar’s eClinical system, that contains 8,000,000 records or so, including PCC’s 130,000 records.

You and I have heard that it takes a $ billion to develop a new medication.  Actually, the costs have now reached 4-12 billion per new med, because the costs of developing a new med in growing [numerator] and the number of new meds successfully developed [denominator] is decreasing.  How to improve the denominator? Two thoughts:

1] Develop precision medicine. 

2] Medication repositions [jargon for finding off label uses].

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September 21

Folks,

This Sentinel will only focus on suicide.

We need to remember that the Washington Psychiatric Society has asked that we not use the term, “committed suicide.” It should not be seen as a crime.

Last Wednesday was World Suicide Prevention Day. I am not aware of any prospective studies that demonstrated how to prevent suicides.  A century ago, 1915, the following was in the American Journal of Psychiatry:

“The problem we have to study is one of preventive medicine, and concerns thousands of suicides due to distress of mind, the result of psycho-sociological conditions, before which, to judge by their great increase, society shows a helplessness which, in view of present psychopathological knowledge, is reprehensible.”

Can we conclude the same in 2015?  Over the past century, has there been any progress on preventing suicides?

A number of retrospective studies have suggested that those parts of the world that have drinking water that contains lithium is associated with fewer suicides. 

An economic retrospective study [Brit J Psychiatry, 09 Sep 2014] concluded that the Great Recession was associated with at least 10,000 additional economic suicides between 2008 and 2010. They suggest that a range of interventions, from upstream return–to–work programs through to antidepressant prescriptions may help mitigate suicide risk during economic downturn.

The recent suicide of Robin Williams led to a lot of media attention to theories as to why people suicide. Not explained in the theories I have seen is why our most privileged citizens, white males, have the highest rate of suicides and one of the least privileged, African-American women, have the least.

A couple of years ago (off-duty on a Sunday, not part of my County work, not part of patient-physician relationship, not being paid), I saw a man in his 70s at the request of his daughter. She wanted me to see her father because he had decided to kill himself. He and I talked for about 90 minutes. He had been a huge success in his field and made millions. He was experiencing cognitive decline and did not want to live with such a condition. Furthermore, he thought society was better served by people with declining, irreversible, unsatisfying mental conditions to kill themselves rather than slowly dying and being a burden on his family and on society. He talked of the enormous costs to society taking care of the very demented in their later years. Mental status found him irritated at the beginning of the interview because his daughter wanted his belief reviewed, but the two of us got passed that and has a thorough review of his thinking. Cognitively, he was not as sharp as he had been in past years, but he was well oriented. Further, his beliefs were not delusional, but shared by members of the Hemlock Society. I so informed him and his daughter.

Two days later his daughter called, she thanked me and told me that her father had died comfortably using helium gas.

Seeing this gentleman reminded me of George Eastman, the highly successful executive of Kodak, who may have been speaking for some other older white males, when at the age of 78, in 1932, put a bullet through his head after leaving the following neatly written note:

“Dear Friends. My work is done. GE”

Maybe African-American women never feel their work is done?

Roger

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September 16

Folks,

Sunday’s Wall Street Journal reported Saturday that the list of approaches to stress that some are advocating which are NOT yet part of APA Guidelines for managing stress include:  acupuncture, hypnosis, tapping therapy, bright-light therapy, brain-wave optimization, high-pressure oxygen, Native-American healing, Botox, marijuana, scuba diving, hiking, horseback riding, dance, drama, yoga, music therapy, tai chi, companion dogs, blueberry extract, and fish oil.  A new book, ACID TEST, presents anecdotal support of LSD and MDMA for PTSD.  [We researched LSD for schizophrenia at St Es, and LSD struck out.]

The University of Maryland runs a Center for Problem Gambling which has a 24 hour help line and will connect patients to specially trained counselors. Their website is http://www.mdproblemgambling.com/.

People with AB blood are 82% more likely to develop thinking and memory problems that can lead to dementia than people with other blood types [10 Sep 2014 Neurology].

Twelve week intensive autism therapy in infants appeared to head off autism in five or seven babies [this month’s J of Autism and Developmental Disorders].

Sad to hear, during the McDonnell trial, “mental illness” being equated with “nutbag.”

Per our interest in lakphy [lack of physical exercise], a report that sedentary behavior is associated with depression [British Journal of Sports.09/09/2014]. 

While fish has been constantly championed for its positive neurocognitive effects, fish oil supplement has often been found to be ineffective. Now, in Alzheimer’s & Dementia, 07/30/2014, there is a report that is positive regarding the fish oil protecting neurons.  So, the issue remains unsettled.

I have been teaching that we lowering the barriers to PTSD by removing the subjective reaction required of prior DSMs’ PTSD criteria.  I am wrong again.  Apparently, DSM-5’s organization of the other criteria has raised the barriers.  For those wanting to make a DSM-IV-TR PTSD diagnosis, I would guess that it is consistent with DSM-5 to use the code 309.89, with the name: “DSM-IV-TR Version of PTSD.”

St Es’s CMHC for Anacostia, “Area D CMHC,” America’s most comprehensive CMHC, 1967 – 1987, had a children’s ward where the staff, usually a psychiatrist, would have the kids jog with him for a mile every morning.  We did no control study as to its effectiveness.  Now, two studies 20 – 30 minutes of jogging produced marked improvements in ADHD kid’s math and reading comprehension, suggesting PE has an important role in school. [Reviewed in Sunday’s NY Times and J Abnormal Child Psychology, 9 Sep 2014].

The American Geriatrics Society has included benzodiazepines on its list of inappropriate drugs for seniors.  In this month’s BJP, a paper saying use of benzodiazepines among seniors for more than 3 months increases the chances of Alzheimer’s, but some experts say that conclusion is premature.

I am impressed with Healthline.com's ability to assist supportive psychotherapy in patients who like the internet.

From this month’s J of AACAP:

1] On chromosome 22, deletion at the q11DS location, markedly increases a person’s chance of having a broad range of psychopathology. Researchers are especially interested in the increased frequency of schizophrenia.  Old timers on reading about this may wonder if it is time to bring back Bleuler’s “schizophrenic thought disorder” to capture what this deletion causes.  At some point in the future, it probably will make more sense to say “22q11 Deletion” than to jam it into the various DSM syndromes which it manifests, e.g., schizophrenia, ADHD, GAD, and others.

2] Mentally ill children and adolescents, treated with an antipsychotic, compared with such children not so treated, has doubled the hazard of being treated with an oral antidiabetic later in life.

Roger

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August 4

Folks,

A wish of the DSM-5 Editor, David Kupfer, was a reduction of the number of psychiatric disorders.  He got his wish, only 324 coded conditions compared to DSM-IV’s 374.  Much of the change was achieved by combing disorders and by moving coded conditions to uncoded.  Only two disorders were eliminated: sexual aversion disorder and polysubstance dependence. 

For those who feel constricted by DSM-5 and are not constrained by payers, we have provided a comprehensive listing of psychiatric conditions at RogerPeele.com, which leans on ICD-9-CM, the medical classification in the US.  The outline of the Comprehensive electronic book is below my name.

CMS has scheduled a start date of ICD-10-CM for 1 October 2015.  Very unclear at the moment as to whether Congress will allow that to happen.  If Congress does allow, Dr. Gustavo Goldstein and I will provide training for County folks for ICD-10-CM as we have done with DSM-5. 

The Comprehensive mentioned supra already has a walkover from ICD-9-CM to ICD-10-CM, Chapter 6, Alphabetical listing of DSM-5 Conditions in ICD-9-CM & ICD-10-CM.  We will add other ICD-10-CM material next year when use of ICD-10-CM seems eminent.

In Sentinel # 41, we listed many phobias.  Bill Hudock pointed me to a list much longer: http://phobialist.com/.   Have a look and you’ll probably spot a number of phobias of which you were unaware you had.

Two items coming up in next Wednesday’s JAMA:

1] Bullying in any capacity is associated with higher rates of youth suicidal behavior.

2] An article on “Research on Psychiatric Disorders Targets Inflammation” brings up a number of interesting points including the concept that introducing the eggs of porcine whipworm into the gut of people with Autism might be helpful in reducing some behaviors.  This reminds me of giving malaria to patients with neurosyphilis, introduced in 1876 --and led to one of psychiatry’s three Nobel Prizes [but not awarded to the first one to use malaria therapy]. .   

Speaking of Autism, in Sunday’s NY Times Magazine, is a comprehensive review of autism.
Among its points, 1] experts cannot predict who is going to get “better” when first seen and 2] maybe some of the “symptoms” should be in the same category as homosexuality, not seen as a mental illness.  Applied Behavior Analysis for this condition is well regarded, but frequently fails.

EMDR [Eye Movement Desensitization and Reprocessing] received a positive review in the treatment of subsyndromal mood and trauma symptoms in traumatized bipolar patients [Psychiatry Research, 07/02/2014].

The combination of lithium+olanzapine+clonazepam decreases the symptoms of obsessive compulsive disorder in the patients with bipolar disorder type I. Adding topiramate had a significant additional effect on improvement of the patients with bipolar disorder and obsessive compulsive symptoms. This combination seems to be without serious adverse effects. [J Affective Disorders, 07/31/2014.] 
Headline in July 7 Neurology Times:  “HEADACHES ASSOCIATED WITH SEX ARE NO JOKE” While tension and migraine types are much more common, headaches associated with sex may be related to very serious condition such as a brain aneurysm, stroke, cervical artery dissection, or subdural hematoma. Headaches with sex may be more common with women in the media, but in clinical practice, more common in men.

As to our interest in “lakphy,” our term for lack of physical exercise, one of medicine’s broadest etiologies, two items:

1] This nation’s obesity increase is not associated with eating more calories.  It is associated with lakphy.

2] As to running, speed, distance and running frequency made little difference: Even those who run only once or twice a week, less than six miles a week, and less than 6 mph achieved benefits comparable to those who ran faster and farther. Running regularly for at least six years, however, is associated with the best mortality odds, with a 50 percent lower risk for cardiovascular-related death. So, 21,901 [6x365 + 1] days of running to go. The researchers noted that “not running was almost as important as hypertension” for increasing mortality risk. [August, J American College of Cardiology].

In the July 24 Psychiatric Times, Allen Francis, Editor of DSM-IV, wrote “The neuroscience and genetic revolutions have been astounding in their technical virtuosity and fascinating in their findings—but to date have not helped a single patient.”  Allen would have preferred that a recent award of $650 million go, not to genetic research, but to model program to “improve the dreary lives of our patients.” 

Allen’s suggestion reminds us of the late Richard Jed Wyatt’s, St Es researcher, editorial in Science, 1986, “Scienceless to Homeless.”  Jed pointed out that public policies are never subjected to control studies.  At that time, David Joseph and I took the idea that DHHS use DC, since it lacked the state-county-city governance split, as a site to carry out empirical research on policies.  [The major dispute at the time was what the best approach to prevent homelessness was.]  Dave and I got positive responses at lower level, but when we reached DHHS political level [Republican at that time], the answer was no way are we going to give that mission and money to a Democratic strong hold, DC.   .

Roger

Outline of electronic book at RogerPeele.com:

Comprehensive Psychiatric
ICD-9-CM [CP-ICD-9-CM]
1 July 2014 Edition

1] Introduction

2] Outline history of ICDs

3] Outline history of DSMs

4] Comprehensive alphabetical listing of psychiatric conditions including: 
            A] DSM-IV-TR conditions
            B] DSM-5 conditions\
            C] Side effect conditions common with psychiatric medications
            D] V-codes of relevance to psychiatry
            E] Some conditions suggested for future ICDs/DSMs

5] Numerical Listing of Psychiatric Conditions in ICD-9-CM


6] Alphabetical listing of DSM-5 Conditions in ICD-9-CM & ICD-10-CM

7] Summary of Changes from DSM-IV-TR to DSM-5  

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

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

10] Nomenclature changes in DSM-5

11] Future in psychiatric diagnosing

Please email suggested improvements to: RogerPeele@aol.com  

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July 16

Folks,
Peanuts, July 3, finds Charlie Brown going to Lucy’s stand that provides psychiatrist help for 5 cent. Lucy, apparently not a believer in analytic neutrality, tells Charlie before he gets have way through his first sentence that he has iatrophobia, fear of going to the doctor. This reminds us that patients sometimes report episodes of discomfort but have trouble pinpointing the circumstances.  Below my name, a long-list of potential phobias, to which a patient on seeing the list, might point to one and say, “that’s it!” Please let me know of any phobias you have seen that are missing in my list.

We’ve suggested that lack of physical exercise needs a term, maybe “Lakphy.” It already has its unique ICD-9-CM code, V69.0. In last week’s Am J of Med, a review concluded that the increase in obesity in this country is not the result of increased calorie consumption, but V69.0.  Another study concluded that a walking program may prevent or postpone a decline in executive function in those who had been sedentary. [Am J Geriatric Psychiatry, August, 2014]. Last Tuesday, CDC reported that one in four people [25.4%] across the US admit doing no exercise at all.”

As to gains in weight among those taking psychiatric meds, a study of antidepressants, found that bupropion, the tricyclic antidepressants nortriptyline and amitriptyline were associated with less weight gain than the selective serotonin reuptake inhibitor (SSRI) citalopram. [JAMA Psychiatry. June 4, 2014.]
A study comparing lethality of risperidone, olanzapine, quetiapine, haloperidol, aripiprazole, and ziprasidone being prescribed for those >65 y/o found risperidone, olanzapine and haloperidol showed a dose-response relation in mortality risk. Mortality risk was found to be increased for haloperidol and decreased for quetiapine and olanzapine. [Brit J Psychiatry, 07/09/2014.]  I gather the study did not control for what precipitated the need to prescribe an antipsychotic, that haloperidol may have been used more frequently in people with delirium, a highly lethal condition [half die within six months].

When it comes to antidepressant-medication-related weight gain, a study, which looked at antidepressant use during a 1-year period, showed that bupropion and the tricyclic antidepressants nortriptyline and amitriptyline were associated with less weight gain than the selective serotonin reuptake inhibitor (SSRI) citalopram.[June 4 in JAMA Psychiatry.]

A listing of the six top US psychiatric hospitals as rated by physicians, find two are in Maryland. [Listed: Mass General, New York’s Presbyterian, Johns Hopkins, McLean, Menninger, Sheppard and Enoch Pratt]

The county’s most prominent psychiatrist, E. Fuller Torrey, champions the importance of the concept of anosognosia, a term used when the ill patient is unaware they are ill. For those wanting to document anosognosia, the code is 780.99.

 

Roger

Following are a list of phobias.  If you see some not on the list, please let me know.

Acrophobia – Fear of heights [about half the population]
Algophobia - Fear of pain. 
Agoraphobia - Fear of open spaces or crowds. [About a sixth of the population] 
Aichmophobia - Fear of needles or pointed objects.
Amaxophobia - Fear of riding in a car. 
Androphobia - Fear of men.
Anginophobia - Fear of angina or choking.
Anthrophobia - Fear of flowers.
Anthropophobia - Fear of people or society.
Aphenphosmphobia - Fear of being touched.
Arachnophobia - Fear of spiders.
Arithmophobia - Fear of numbers.
Astraphobia - Fear of thunder and lightning.
Ataxophobia - Fear of disorder or untidiness.
Atelophobia - Fear of imperfection.
Atychiphobia - Fear of failure.
Autophobia - Fear of being alone.
Bacteriophobia - Fear of bacteria.
Barophobia - Fear of gravity.
Bathmophobia - Fear of stairs or steep slopes.
Batrachophobia - Fear of amphibians.
Belonephobia - Fear of pins and needles.
Bibliophobia - Fear of books.
Botanophobia - Fear of plants.
Cacophobia - Fear of ugliness.
Catagelophobia - Fear of being ridiculed.
Catoptrophobia - Fear of mirrors.
Chionophobia - Fear of snow.
Chromophobia - Fear of colors.
Chronomentrophobia - Fear of clocks.
Claustrophobia - Fear of confined spaces. [About a third of the population] 
Coulrophobia - Fear of clowns.
Cyberphobia - Fear of computers.
Cynophobia - Fear of dogs.
Dendrophobia - Fear of trees.
Dentophobia - Fear of dentists.
Domatophobia - Fear of houses.
Dystychiphobia - Fear of accidents.
Ecophobia - Fear of the home.
Elurophobia - Fear of cats.
Entomophobia - Fear of insects.
Ephebiphobia - Fear of teenagers.
Equinophobia - Fear of horses.
Gamophobia - Fear of marriage.
Genuphobia - Fear of knees.
Glossophobia - Fear of speaking in public.
Gynophobia - Fear of women.
Heliophobia - Fear of the sun.
Hemophobia - Fear of blood. [About a fifth of the population]
Herpetophobia - Fear of reptiles.
Hydrophobia - Fear of water.
Hypochonria - Fear of illness.
Iatrophobia - Fear of doctors.
Insectophobia - Fear of insects.
Koinoniphobia - Fear of rooms.
Leukophobia - Fear of the color white.
Lilapsophobia - Fear of tornadoes and hurricanes.
Lockiophobia - Fear of childbirth.
Mageirocophobia - Fear of cooking.
Megalophobia - Fear of large things.
Melanophobia - Fear of the color black.
Microphobia - Fear of small things.
Mysophobia - Fear of dirt and germs.
Necrophobia - Fear of death or dead things.
Neophobia – fear of newness, such as a new place to life, such as a new-appearing medication
Noctiphobia - Fear of the night.
Nosocomephobia - Fear of hospitals.
Nyctophobia - Fear of the dark.
Obesophobia - Fear of gaining weight.
Octophobia - Fear of the figure 8.
Ombrophobia - Fear of rain.
Ophidiophobia - Fear of snakes.
Ornithophobia - Fear of birds.
Papyrophobia - Fear of paper.
Pathophobia - Fear of disease.
Pedophobia - Fear of children.
Philophobia - Fear of love.
Phobophobia - Fear of phobias.
Podophobia - Fear of feet.
Porphyrophobia - Fear of the color purple.
Pteridophobia - Fear of ferns.
Pteromerhanophobia - Fear of flying. [About 1/3 of the population]
Pyrophobia - Fear of fire.
Samhainophobia - Fear of Halloween.
Scolionophobia - Fear of school.
Selenophobia - Fear of the moon.
Sociophobia - Fear of social evaluation.
Somniphobia - Fear of sleep.
Tachophobia - Fear of speed.
Technophobia - Fear of technology.
Tonitrophobia - Fear of thunder.
Trypanophobia - Fear of needles / injections.
Venustraphobia - Fear of beautiful women.
Verminophobia - Fear of germs.
Wiccaphobia - Fear of witches and witchcraft.
Xenophobia - Fear of strangers or foreigners.
Zoophobia - Fear of animals.

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June 26

Folks,

In a study that prospectively assessed the skeletal effects of psychotropic drugs, researchers found that long-term SSRI treatment in children and adolescents was associated with reduced bone mass, and that long-term risperidone treatment was associated with failure to accrue bone mass. [American Society of Clinical Psychopharmacology 2014 Annual Meeting.]

Patients with Borderline Syndrome and patients with Bipolar Disorder have increased risk of suicide.  In patients with both, the risk is additive [This month’s J Personality Disorders].

Relative to the DOD’s and the VA’s treatment of service men and women and of veterans’ treatment for PTSD, there has been a lot of negative press. Cam Ritchie, who many of you know, now at Georgetown, is quoted as pointing out: "What we found over and over again were really hardworking, well-intentioned people who wanted to do the best they could, but they either didn’t have an administrative structure to support them, or enough staff, or they had an overwhelming number of patients."

Report suggests that watching too much TV is linked to a higher risk of early death [Current J Amer Heart Ass].  If you want to code for such, I guess the closest choice is V69.0 = Lack of Physical Exercise.  [We have suggested that coining a specific term might be helpful, such as “Lakphy,” just as conceptualizing overweigh has benefitted with the use of the more medical “obesity.”]

Will patients with major depression with atypical features and a history of treatment resistance already on 60 to 120mg/day duloxetine benefit with the additions of 150/300mg/day bupropion? A study found that after six weeks, improvement was not better than adding a placebo [Neuropsychopharmacology, 05/23/2014].  

Relative to the trend to avoid handshaking, the following reflection in last week’s JAMA: “In an attempt to avoid contracting or spreading infection, many individuals have made their own efforts to avoid shaking hands in various settings but, in doing so, may face social, political, and even financial risks.”

Children and young adults who start antidepressant therapy at higher than modal doses appear to be at greater risk for suicidal behavior during the first 90 days of treatment, a study defining modal as doses for citalopram, sertraline, and fluoxetine of 20 mg/d, 50 mg/d, and 20 mg/d, respectively. The rate of deliberate self-harm among individuals 24 years or younger who started antidepressant therapy at doses higher than modal doses (up to maximum daily doses of 40 mg/d, 200 mg/d, and 80 mg/d for citalopram, sertraline, and fluoxetine, respectively) was about twice as high as that in a matched group of patients who received modal-dose therapy. For adults 25 to 64 years old, however, there was no difference in risk for suicidal behavior when using > model doses. [JAMA Intern Med. 2014;174[6]:899-909.]

We have been slow to update our Board preparation questions, but some topics have been updated this year: Medications, Suicide, Signs and symptoms, ethical issues, and legal issues at RogerPeele.com >> “clinical” >> “ABPN.”  We could rationalize our sluggishness by pointing out that the Boards still use questions developed years ago.

Roger

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June 24

Folks,

DSMs, especially the last four DSMs, have been virtually 100% syndromes.  Yet many a patient poorly fits any of the syndromes.  At times, it may be attractive to focus on the patient’s symptom, not select a syndrome.  Below my name are symptoms that are available in the rest of medicine, ICD-9-CM, and may be appropriate for some of our patients.

A decade ago, FDA implemented a black-box warning that children and adolescents taking antidepressants were at increased risk of suicidality (suicidal ideation and behavior). A study in this week’s BMJ reported that that one year after the implementation of the warning, use of antidepressants dropped 31 percent among adolescents, 24.3 percent among young adults, and 14.5 percent among adults. Simultaneously, there was a 21.7 percent increase in suicide attempts by psychotropic drug poisoning among adolescents, and a 33.7 percent increase for such among young adults. At the time, 2003, Eist and others noted that there had not been an increase in suicide associated with the meds, that suicidal ideation and behavior is not suicide.  The same theme comes up this time: The number of deaths by suicide did not change for any age group.

A study found that lithium [medium dose, 900 mg/d] and quetiapine [medium dose, 300 mg/d] used with Bipolar I and II patients saw only one fourth deemed well at the end of six months.  Studied allowed for polypharm, and most patients were prescribed additional psychiatric meds besides the Li or the quetiapine.  Key surprise was that Li and quetiapine did equally well or equally badly depending on one’s expectations. http://www.medscape.com/viewarticle/826967]
NY Times, June 16, 17 and 23 have had articles on perinatal depression [aka postpartum depression], a topic about which the DSMs have been phobic because of a reluctance to have mental disorders the DSMs that only pertain to women.  So, in DSM-5, only as an uncoded specifier in depression, even though often manifested by panic and other anxiety symptoms.  Also, DSM-5 missed the opportunity to point out that it occurs in men.  DSM-5’s attitude separates us from the rest of medicine that uses the OB code 648.4 for this condition.

Maryland was listed as the 8th most stressed state in a recent study.  I guess that the sample included a lot of people who use 270 or 495.

The recommended treatment for Hoarding Disorder is a bit of a mouth-full: “multicomponent cognitive behavioral therapy – including education about hoarding disorder, goal-setting, motivation-enhancing techniques, organizing and decision-making skills training, and practice in sorting and discarding objects and resisting the acquisition of new items – should be offered and outcomes monitored with the use of standardized rating scales. [NEJM – May 22, 2014]  

Roger

Altered mental status, 780.97
Apathy, 799.25
Attention deficit, 799.51
Cachexia, 799.4
Cognitive deficit, 799.52
Decreased libido, 799.81
Delayed milestones, 783.42
Demoralization 799.25
Emotional lability, 799.24
Excessive crying of adolescent, 780.95
Excessive crying of adult, 780.95
Excessive crying of infant, 780.92
Failure to thrive, adult, 783.7
Failure to thrive, child, 783.41
Fussy infant, 780.91
Hallucinations
          Auditory, 780.1
          Gustatory, 780.1
          Olfactory, 780.1
          Tactile, 780.1
          Visual, 368.16
Identity disorder, 313.82
Impulsivity, 799.23
Irritability, 799.22
Lethargy, 780.79
Memory loss, 780.93
Nervousness, 799.21
Polyphagia, 783.6
Psychomotor deficit, 799.54
Suicidal risk, 300.9

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June 7

Folks,

This Sentinel will only focus on ten items from last month’s APA annual meeting that we did not mention in prior Sentinels.

1] In treating severely depressed patients, belief in God was associated with treatment responders in a study done at McLean Hospital.  Non-believersdid not do as well.

2] Ten percent of cannabis used end up dependent.

3] As to treating hypersexuality, a condition in ICD-9-CM with the code 302.89 and the names nymphomania [females] and satyriasis [males], not in DSM-5, suggested treatments discussed were androgen reduction agents and SSRIs.

4] While coercion in institutions has diminished, new forms have evolved in the community: mental health courts, outpatient commitment, probation and parole requirements, and use of informal leverage over patient’s money, housing, parental rights, and the like.

5] Anosognosia is found in 50% of people with schizophrenia.

6] The reluctance to diagnose adolescence with “Borderline Personality Disorder” [BPD] is because:
A] BPD label connotes severity and non-malleability, which may negatively affect the adolescence’s self-concept and bias others’ perception of him/her.
B] Can we really diagnose a personality disorder prior to the person completion of their identity?
C] Can we really distinguish borderline features from normal adolescence?
{Those of you who have heard Dr. Gustavo Goldstein’s DSM-5 talks over the past year will know that, in addition to the above three reasons, he also points out that the brain is undergoing many changes until the early twenties, changes that could impact the evolving personality.  Yet, we would like to see the adolescents get the psychotherapy they need.  That is one of the reasons we suggest using the name, “Borderline Syndrome,” not Borderline Personality Disorder}

7] A study of adolescents hospitalized with borderline syndrome were compared to adolescents not in any treatment, and it was found that adolescents with borderline syndrome had a poorer relationship with parents, peers and teachers, but had a better relationship than “normals” with  a romantic partner.    

8] Psychotherapies shown to be effective with borderline syndrome include
Dialectical behavioral therapy,
Mentalization-based therapy,
Transference-focused psychotherapy
Schema-based therapy
Cognitive behavior therapy
General psychiatric management
Manual-assisted cognitive therapy
Good psychiatric management

9] Yoga recommended to address ADHD, PTSD, and emotional dysregulation in elementary school children.

10] Contrary to the usual stereotypes, a study in California found
older age is associated with higher well-being and better
psychosocial functioning, despite worsening physical health.

Roger

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May 23

Folks,

Time for a pop quiz: Name the US's largest inpatient psychiatric facility.  [Answer is below my name.]

May 22’s NEJM:

1] Consider in the differential of Hoarding disorder, that is, consider before concluding the person has Hoarding disorder: a] MDD, b] OCD, c] Psychosis, d] Neurocognitive disorder, and e] autism spectrum disorder.

2] Relative to treatment of Hoarding Disorder, strongest evidence is for CBT that is specifically tailored to hoarding.  [Paroxetine and venlafaxine have achieved positive results in some non-placebo trials.] [Montgomery County’s Aging and Disability Service has developed a pictured severity scale for this disorder.  Email me if you want a copy.]

For social anxiety disorder, both psychodynamic psychotherapy and cognitive behavior therapy were found to be effective.  [Depression and Anxiety, 02/28/2014].  
Differentiating Bipolar disorders and borderline syndrome: While similar as to mood liability and impulsivity, they differ notably on all other diagnostic validators as well as on past sexual abuse [borderline syndrome], parasuicidal self-harm [borderline syndrome], and family history [bipolar]. [Acta Psychiatrica Scandinavica, 02/27/2014

How does chlorpromazine, the first antipsychotic [1952], compare with the 43 other antipsychotics?  Of the antipsychotics available in the US, only clozapine and olanzapine are more efficacious than chlorpromazine, but due to the low number of pts in each study, the comparisons are regarded as underpowered. [European Neuropsychopharmacology, 05/21/2014]

ASAM’s Standards of Care for the Addiction Specialist Physician can be obtained at:

 http://www.asam.org/docs/default-source/publications/standards-of-care-final-design-document.pdf

Maryland has seen three positive trends from 2010 through 2013 in its behavioral health system:
          1] Decrease in adult smoking, but still above 50%
          2] Decrease in adolescent smoking, but still above 10%
          3] Decrease in number of clients/patients being arrested

If you are looking for Bipolar I, mixed type, in DSM-5, note that title and its code, 296.6x [x = the 8 severity codes] are not in DSM-5. Since 296.6x is still in ICD-9-CM, you will probably find you can still use 296.6x for record and billing purposes.

May 16 AJP included: “the unexpected loss of a loved one can trigger a range of psychiatric disorders, including mania, in patients with no history of mental illness.”  Suggested coding: V62.89 Loss of loved one.

We’ve all seen suicides when a pt’s situation improves.  For example, after being on a psychiatric ward, then discharged to a nice single apartment, and a week or two later, we hear he [usually he] hanged himself.  A common conclusion is that the person stopped taking their meds.  Also, sometimes we have hypothesized, especially with people who have schizophrenia, that neophobia was the problem.  In talking to Ellen Brown, she brought up a third option, somewhat related to neophobia: he couldn’t handle the lack of stimulus.  Instead of being in a crowded setting where he had been for months or years, he was placed in a setting that seemed cavernous, empty, very lonely, too distressing.

"Physician aid in dying" has replaced "assisted suicide" and is legal Oregon, Vermont, Montana, New Mexico, and Washington state. Criteria: 1] adult, 2] terminally ill and 3] mentally competent [JAMA 21 May].   So, I gather we have a role in approving physician aid in dying. “Mentally competent” seems like a reasonable question.  I’ve always feared we might someday be asked to say whether the person is “normal.”

Each year it is wise we remind ourselves of Harold Eist’s reflections [2001] on my County position, Chief Psychiatrist: “This position has become a roosting place for quislings, cowards, petains, mountebanks, other forms of scoundrels, and the servant of inertia.”

Some of your golfing friends from Virginia may say they suffer from the “yips,” “freezing,” “whiskey fingers,” and so forth?  Being from Montgomery County, however, clinical sophistication is expected: “focal dystonia” [333.89]. Its cousin, migigraphia [writer’s cramp] is coded 333.84. Next Monday’s, May 26, The New Yorker mentions dozens of treatments for focal dystonia.

Roger

Answer to pop quiz: Chicago's Cook County jail.  Those of you who said LA County Jail or King County Jail [NY] were close.

There are well over 100 national psychiatric organizations, but none focus on Counties. Last year we had the American Psychiatric Association develop the concept of Sections.  The first Section to evolve is Section on Senior Psychiatrists.  Next we may help Hind Benjelloun develop a Section on Telepsychiatry.  After that has been achieved, maybe we will promote a Section on County Psychiatrists.

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May 20

Folks,

DSM-5 is confusing as to diagnosing Neurodevelopmental Disorder associated with Prenatal Alcohol Disorder ND-PAE, listing two names, the other being “Neurobehavioral Disorder associated with Prenatal Alcohol Disorder. The international authority, Potomac’s Susan Rich, MD, prefers ”Neurodevelopmental.”  When so diagnosing, use code 315.8. As for the pts who fully meet Fetal Alcohol Syndrome, the code is 760.71.

All DSMs, going back to DSM-I [1952] have had the primary goal of increasing reliability.  [Validity has been too far a reach, although in some theoretical circles, of course, the cause of almost all disorders is known.] Since it was felt that DSM-I and DSM-II failed as to reliability, DSM-III [1980] switched from the usual medical model of defining by prototype matching to defining by criteria sets. Often the criteria sets are tight, only allowing one combination of signs to define the Disorder. 

Some DSM criteria sets are loose. Borderline syndrome has 256 possible combinations of signs.  So, if you diagnose me with borderline, there is 0.4% chance that another person so diagnosed will have the same combination of signs. 

If you diagnose me as PTSD, there is virtually no chance anyone else will have the same combination of signs as there are 9,541,800 possible variations of PTSD Disorder’s 24 signs. Of course, even nearly ten million is far short of the possible variations of signs of mental stress as many mood, anxiety, sleep, sexual, and other conditions are outside PTSD.

The resource for Guidelines that meet federal standards is the Agency for Healthcare Research and Quality [AHRQ].  Today, they released their decisions on psychiatry’s’ primary etiological agent; mental stress. 

http://www.guideline.gov/content.aspx?f=rss&id=47588&osrc=12

This 12-page documents list:

1] 73 procedures [e.g., Beck Depression Inventory and treatments [e.g., SSRIs, “return to work”] they recommend,

2] 17 still being studied [e.g., Folate], and

3] 22 not recommended [e.g., PHQ-9 and vilazodone].

Some feel that pts are poorly served with DSM’s term “Personality Disorder.”  It is pejorative.  It characterizes the whole person.  It gives an unfortunate identity to some during a time they are gaining an identity, such as adolescents. It incorrectly implies a tie to the science of personality. In dodging its use, clinicians may also dodge the best treatment: psychotherapy, leaving these people only getting a medication.

For those who wish and are in circumstances in which they are free to use the nomenclature they prefer, such as situations that only use codes, ignores nomenclature, you might consider:

Paranoid syndrome, 301.0
Cyclothymic syndrome, 301.13
Schizoid syndrome, 301.20
Schizotypal disorder, 301.22
Anancastic syndrome, 300.3*
Histrionic syndrome, 301.50
Dependent syndrome, 301.6
Antisocial syndrome, 301.7
Narcissistic syndrome, 301.81
Avoidant syndrome, 301.82
Borderline syndrome, 301.83
Passive-aggressive syndrome, 301.84**

*Anancastic is an accepted alternative in ICD-9-CM to obsessive compulsive personality disorder and suggested here to avoid confusion with obsessive compulsive disorder.

**Although not in DSM-5, 301.84 is part of ICD-9-CM.

Roger

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May 12

Folks,

Nine items from the APA Annual Meeting follows.  Keep in mind that all medication indicationsare off-label.

1] The list of internet-based CBT [iCBT] continues to grow: depression, social anxietydisorder, OCD, Body Dysmorphic Disorder, and irritable bowel syndrome.

2] In preventing relapse of MDD, a study found fluoxetine and escitalopram did better thanparoxetine and sertraline.  Co-treatment with psychotherapy markedly reduced relapse in allgroups.

3] Exposure and response/ritual prevention remains the treatment of choice for obsessive-compulsive disorder, but lack of such therapists means many are not so treated.

4] Another concern about underuse, but more understandable:  Clozapine is the only antipsychotic approved for treatment resistant schizophrenia, but is used in only 6% of suchpatients.

5] Supported employment and education programs report success rates of 83-85% success inreturning people with first break schizophrenia in comparison to 29% with routine treatment and41% with conventional vocational rehab.

6] For pts who have both MDD and PTSD, those who have had ECT have a reduced risk of all-cause mortality.

7] For panic disorder, comparing paroxetine and clonazepam, both were efficacious, butclonazepam was better tolerated by the pts.

8] For trichotillomania and skin-picking disorder, N-Acetylcysteine, 1200-1800 mg/d, helped [smallstudy and not-controlled].

9] Quetiapine XR 150 or 300 mg/d pts with borderline syndrome got positive results incomparison to placebo, but more on meds dropped out.

More from Annual meeting later this week.


This month's J of AACAP:
1] Moving three or more times during childhood may lead to increase bullying and increased psychotic signs in adolescent.  If you want to code, I would suggest V60.89 School mobility.

2] Mothers' suicide attempts are associated with increased risk of self harm in their children. Suggested code: V61.8 Mother has had suicide attempt/s.

Today’s Baltimore Sun: Gay rights activists in Maryland hope to ban clinical therapy for childrenthat are based on the notion that the children’s sexual orientation can change. Some medicalassociations have warned against this therapy, which is sometimes referred to as reparativetherapy or conversion therapy.

NEJM, 8 May 2014: Paroxetine, starting 10-20 and increasing gradually if needed to 40 mg/dFDA approved for menopausal hot flashes even though an FDA Advisory Committeerecommended against approval.

In today's The New Yorker, a day after Mother's Day, a review of narcissistic personalitydisorder with its history of blaming the mother for narcissism [Freud: penis envy; Ferenczi: lack of maternal empathy and affection; Kohut: mother's failure to support her child's natural sense of omnipotence].  

The article suggests that there could be both bad narcissism and good narcissism.  [I guess it only killed Narcissus?]  DSMs only recognize the bad, but, as some of you know, I'm tempted to launch a motio [Action Paper] suggesting that we cease labeling personalities negatively,
that we use a term like, "Narcissistic Syndrome" and allow that not all need be treated, that the syndrome might work well for some in some circumstances.

Roger

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May 10

Folks,

Some notes from this year’s APA Annual meeting [we will have more in future Sentinels next week]:

1] Paul Appelbaum has made the statement to the media, to congressional committees, to the White House, and to colleagues that mental illness is only seen in 4% of the homicides associated with guns.  We asked him if that included substance-related conditions and he said, “No, that would place the percentage over 50%.”  So, we need to be aware of that when quoting Paul or others as to “4%.”

2] Vice-President Biden gave a very winning talk on the need for more psychiatrists, but he didn’t clarify how this nation will get pass the bottleneck: No significant increase in the number of psychiatric residency positions.

3] Marijuana got some bad reviews: 10% of users end up becoming dependent, and increase risk of depression and psychosis.  Off label meds mentioned as to treatment or marihuana dependence included gabapentin and dronabinol.

4] Memantine did not produce significantly different results than placebo for patients with autism.

5] Armodafinil did not produce significantly different results as an adjunct for patients with Bipolar I depression

6] Cam Ritchie pointed out that art therapy, animal therapy, acupuncture, yoga, and mindfulness have a role in managing vets with PTSD.

7] We had a motion pass the Assembly that the ABPN use DSM-5 for the 2015 exams rather than DSM-IV-TR, so that those of us studying for next year’s exam will know what to study.  At this meeting, it was clear that in a few months, all the texts one usually studies for the Boards will be DSM-5.  Expecting us to study older books seems very confusing.  This motion may not be adopted by the APA Board of Trustees, and even if it passes the APA Board of Trustees, ABPN can ignore this request.

8] Fuller Torrey, at St Es from 1975 till about 1998, was honored for his work. He got the longest standing ovation of anyone at the meeting.  Quite a change from being an outcast in the 70s, 80s, and 90s.

Tired of saying “biopsychosocial?” Want to sound avant-garde?  Then, use “circuit dynamics,” but to remain politically correct, be sure to imply that psychological and social factors can impact circuit’s dynamics.

From April 30 JAMA Psychiatry, comparing psychotherapy and psychopharm: In the few head-to-head comparisons, there was a trend in favor of psychotherapy for relapse prevention in depression and for bulimia, whereas pharmacotherapy was more effective for dysthymic disorder and schizophrenia. As for the combination studies, for all but posttraumatic stress disorder and psychodynamic therapy for schizophrenia, the addition of psychotherapy to drug therapy was better than drug therapy alone, and vice versa.

Roger

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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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