1] Valproate, already shown to increase the risk of birth defects and thinking problems in offspring whose mothers used the drug during pregnancy may also significantly increase the risk of having a child with an autism spectrum disorder [today’s JAMA].
2] In utero exposure to both SSRIs and non-selective monoamine reuptake inhibitors (tricyclic antidepressants) was associated with an increased risk of autism spectrum disorders, particularly without intellectual disability. Whether this association is causal or reflects the risk of autism with severe depression during pregnancy requires further research. [NY Times, 22April2013]
Fortunately, this County has lots of excellent psychotherapists [including psychiatrists] that can provide an alternative to medications for some of our pregnant patients.
Transcendental meditation substantially reduced symptoms of post-traumatic stress in a group of refugees from the Congolese civil war. Note “substantially.” [April 8 J Traumatic Stress.]
Mindfulness-Based Cognitive Therapy given to patients with fibromyalgia suggested that Therapy reduced depressive symptoms and reduced the impact of the illness, but no improvement in the pain [Cognitive Therapy & Research, 11April2013].
Analysis of fluvoxamine add–on therapy in patients with schizophrenia treated with antipsychotics suggests that fluvoxamine add–on therapy is more beneficial on the psychopathology (especially deficit [“negative”] symptoms) than controls in patients with schizophrenia who are primarily treated with first generation antipsychotics, but fluvoxamine was not helpful with the second generation antipsychotics. [European Arch Psychiatry Clin Neuroscience. 22April2013
Earlier this year, we noted a study that suggested that mortality is not higher in people up to a BMI of 35. In today’s JAMA, the authors admit they did not rule out the possibility that the cut off might be a BMI of 40, that 35-40 BMI might NOT be associated with an increase in mortality.
In Monday’s American Medical News, the headline, “EHR design flaws are causing doctors to revert to paper.” A reminder that EHR user satisfaction decreased from 39% in 2010 to 27% in 2012. Over the years, almost all EHR have been abandoned or replaced. This takes me back to 1967 when I “knew” that an electronic medical record was the best approach to medical records, participated in writing a grant request to NIMH for $2,000,000/year times 5 years to demonstrate the vast superiority of an electronic record. NIMH loved the proposal and had planned to award it to St. Es., but a few months later, St. Es was transferred to NIMH, and the Director of NIMH, Stan Yolles, changed his mind [“Roger, I can’t take ten million dollars from one of my pockets, the largest grant in NIMH history, and slip it into another of my pockets without anyone noticing.”] Thus, I missed out on being authoritative on why the electronic medical record fails, missed out publishing a paper titled, “How to Waste Ten Million Dollars.” This gets back to something Dick Wyatt of St Es pointed out years ago: Epistemologically, clinicians have to go beyond being rational and subject their thinking to controlled studies, but policy makers are satisfied with just being rational, do not take the additional, rigorous empirical step to demonstrate that patients will benefit in a controlled study.
As we know, DSM-5 is to be available May 22. Here is a one-sheet, two-page summary that provides an overview. Additionally, there are a number of books coming out related to DSMs in mid-May, some of which will reflect the County’s successful efforts to abolish the Multiaxial system and block efforts to replace it with additional dimensions.
Some of- your pts may be experiencing a response from insurance companies rejecting a billing of both 99212 and 90836, and similar coding, being told the insurance company does not pay for two codes on one day, and that 90807 still was valid!!!!! Keep in mind that the APA is looking far cases to litigate with obvious parity violations. The address is imus@psych.org, Sam Muszynsky in APA healthcare systems and finance.
Decades ago, one of the District’s Community Mental Health Centers had a way to reduce census. On a Friday morning, they would have the pts who were functioning OK and who volunteered to take a trip to Baltimore get on a bus from DC General to Baltimore’s Inner Harbor with the understanding that the bus would return to DCGH at 5 PM. There were always some who didn’t make the bus’s 5 PM trip back, which some of us called “bus therapy.” In USA Today, 18 April, an article suggesting bus therapy is still being used in Nevada where 400 pts/year are given one-way bus tickets out of Nevada.
Residency Match numbers this year: 4.2 % of American Medical School grads are going into psychiatry, within the range of recent years, 3.9 - 4.5%. 49.9% of the first year residents are IMGs, the highest peercentage yet.
Relative to DSMs, four topics:
1] When working with DSM-IV-TR or DSM-5, there may be psychiatric diagnoses that you want to use but are not in either DSM. They may be available in ICD-9-CM, which applies to all of medicine in the US. DSMs do not remove diagnoses of ICD-9-CM, although a carve-out might attempt to limit its range to only DSM-listed Disorders. ICD-9-CM is thousands of pages, so we have pulled out the psychiatric diagnoses of ICD-9-CM, 32 pages, which can be found at:
An example of a psychiatric disorder not in either DSM but in our 32 pages: Fetal Alcohol Syndrone [760.71]. Still very important, of course, that when using a DSM diagnosis, that one use the crirteria set of the DSM.
2] Last Thursday, CBS TVnews noted that DSM-5 will not include sexual masochism [302,83], fetishism [302.81], transvestism [302.3], and sexual sadism [302.84] as mental disorders. I think most of us agree that saying "good-bye" to those four conditions is a plus. However, should you be treating someone who is so distressed or disabled from the condition, the codes I've listed above remain part of ICD-9-CM. Those condtions will also be part of ICD-10-CM.
3] About a month ago, APA announced that the costs of the hard copy of DSM-5 would be about $200 for non-members and about $160 for APA Members. We launched a motion that DSM-5 be free to APA Members. That motion cleared a governance hurdle last weekend on its way to the APA Assembly in May. Even if the motion is successful in the Assembly, the APA Board will likely decide against making it free to Members. Regardless, the APA has apparently lowered the pricing to $149 for non-members and $119.20 for Members. I gather that the paperback version will be about $133 for non-members. I have no information on the costs of the eletronic version.
4] If any of you belong to a program that would like to have Dr. Gustavo Goldstein and I talk about DSM-5, we are eager to come by and do so. The only cost is hot coffee with cream. Speaking of costs, you have probably received mailings as to ICD-10-CM, due to be implimented 1 October 2014, offering courses in ICD-10-CM for $400. Keep in mind that Dr. Goldstein and I expect to conduct training in ICD-10-CM next year -- also at a cost of hot coffee with cream.
Five studies using mirtazapine, as an adjunct, to improve the deficit ["negative"] signs of schizophrenia found three that were positive, two that failed [Clinical Schizophrenia & Related Psychoses, 03/14/2013]. A summary of these studies did not clarify as to which antipsychotics the mirtazapine was added.
For the pregnant woman in need of her opioid dependence being addressed, which is better as to neonatal and material outcomes: 1] buprenorphine + naloxone maintenance; 2] buprenorphine maintenance; 3] methadone maintenance; 4] methadone-assisted withdrawal? Summary statistics from 7 published studies found no significant differences among the four as to maternal outcomes or neonatal outcomes [Substance Abuse: Research and Treatment 2013:7 61-74].
For severe, refractory OCD, study of seven pts, four improved on 400-600 µg/d of sublingual buprenorphine, i.e., resulted in a 30% reduction in Y-BOCS scores in 4 of 7 patients with OCD. This was not mono-therapy: patients were on SSRIs or clomipramine. The buprenorphine effect occurred within 2 days of treatment and persisted for 1-2 days after discontinuation. [Therapeutic Advances in Psychopharmacology, 03/01/2013 ]
County budget was announced last week for fiscal year 2014 that begins next July 1. The budget provides for five areas of foci:
· Strengthening infrastructure through Technology Modernization and a focus on efficiencies
·Improving our No Wrong Door approach to service delivery by continuing our work on Service Integration, Equity, Improving access for all vulnerable populations and improving the quality of our service delivery
·Continue to expand Healthcare Access to the vulnerable and maximize our efforts through healthcare reform
·Continue our efforts to strengthen our partnership with our non-profit sector
·Strategically plan for and deliver services using data in order to be more accountable
Unknown when Maryland will change to DSM-5. July 1?, October 1? January 1? Regardless, we want local clinicians to be ahead of everyone -- as usual. In each Sentinel, we plan to bring up one DSM-5 topic to get us ready.
Today, a note on DSM-5’s Personality Disorders. There was quite an interest among researchers to change the DSM-IV-TR Personality Disorder section to a trait-based system. One would score the severity of up to two dozen or so traits, then match the trait findings for the relevant Personality Disorder. We and many others argued against a replacement, we offered a compromise that was rejected, and so Personality Disorders will be one the sections of DSM-5 that is least changed. The trait-based system will be in DSM-5's Section Three, disorders in need of further study.
Any etiological agent in psychiatry [about 44% of DSM-IV-TR has an etiological agent], will have a multiple representations. For example, alcohol is associated with a dozen different syndromes in the DSMs. Mental trauma/stress is also associated with about a dozen, and you know that mental trauma/stress is associated with many more than the DSM lists. Thus, a study in Lancet, 28Feb2013, found similar genetic findings for five disorders: Schizophrenia, Bipolar I, MDD, autism spectrum, and ADHD. We would predict even less specificity, that those genetic findings would also be seen in anxiety disorders and substance related disorders had they looked.
Another study concluding that there is no association between exposure to SSRIs during pregnancy and a] stillbirths or 2] neonatal mortality[AJP, this month].
Three items from JAMA, 20Feb2013:
A] A reminder of FDA's recent announcement recommending dose of 5 mg for immediate release zolpidem and 6.25 mg of extended release, especially recommended for women. Focus of article was to prevent morning car accidents.
B] An article on specific case of a woman with early waking, 3 AM, states that: "A thorough clinical history is often sufficient to identify factors that contribute to insomnia. Behavioral treatments should be used when possible. Hypnotic medications are also efficacious but must be carefully monitored for adverse effects." The physician of this patient with 3 AM-awaking brought up using doxepin [3-6 mg] if a thorough examination doesn't find anything and behavioral approaches fail.
C] Decades ago, Richard Jed Wyatt [St Es] had an editorial in Science pointing to the lack of science in developing Public Health Policy, an unwillingness to do controlled studies before this nation adopted a health care policy. In this JAMA it is pointed out that a review of 34 Medicare-funded demonstration programs using enhanced coordination of care for pts with chronic conditions concluded that the 34 programs failed to show a positive effect on both quality and costs.
As to mental health carve outs, some have concluded that mental health carveouts handing of insurance claims is discriminatory in that they appeared not be ready for CPT coding that went into effect 1 Jan 2013.
In the late 1960s, on the Children's Ward of St. Es’s CMHC for Anacostia [“Area D CMHC”], Ed Black, psychiatrist, reduced the incidence reports on the unit by about 50% through running a mile each morning with the kids 5x/week. In this month’s British J Sports Med, “Short bouts of moderately intense exercise appear to improve the self-control of youngsters and young adults." Some think, the findings could have relevance for treating disorders associated with impaired inhibition, including attention-deficit/hyperactivity disorder (AD/HD) and autism."
Roger
Summary of reasons to abolish the multiaxial system:
Problems with Axis II.
Axis II exists only for the purpose of ensuring:
"that consideration will be given to the possible presence of Personality Disorder and Mental Retardation that might be overlooked.” To segregate a group of patients for the purpose of reminding clinicians of the disorders is inappropriate basis for determining how medical diagnoses should be organized. This segregation has antagonized advocates for the patients and their families.
This segregation has been used to deny access to treatment. Some data systems only record Axis I, so those systems suggest that mental retardation and personality disorders are not present.
Problems with Axis III
Axis III exists only for the purpose of:
"to encourage thoroughness in evaluating and to enhance communication among health care providers." [DSM-IV-TR, page 29]
Again, a diagnostic system should not be based upon pedagogic purposes. Furthermore, the requirement that some disorders must be listed on both Axis I and III is an unnecessary hassle. It is ironic to say that the purpose is to enhance communication among health care providers when psychiatrists tend to avoid the multiaxial system when communicating with other physicians.
Problems with Axis IV
As the developers of the Axial system for DSM-IV said, Axis IV is a "non-diagnostic" Axis {DSM-IV Sourcebook, Volume 3, page 393, 1997] and its “reliability and validity have not yet been systematically studied” [DSM-IV, Sourcebook, Volume 3, page 397].
Problems with Axis V
Exists to report the clinician’s judgment of the patient’s functioning. It is another “non-diagnostic axis” [DSM-IV Sourcebook, 1997, Volume 3, page 393, 1997]. The GAF consists of three independent scales,
1] The severity of the signs [e.g., "depressed mood"],
2] Level of functioning ["temporarily behind in schoolwork"] and
3] Dangerousness to self or others [e.g., "recurrent violence"].
One example. A “15” on Axis V could mean:
1] A teenager making periodic suicidal attempts without clear expectations of death
2] A 25 year old man in manic excitement of insomnia, grandiosity, flight of ideas, and constantly approaching women about the need for sex.
3] A 30 year old woman with borderline personality disorder who habitually smears feces in her boyfriend’s apartment when distraught
4] A 45 year old woman who is mute as part of her catatonia
5] An 87 year old man who is largely incoherent from Alzheimer's
6] Tony Soprano, who is violent at least once a week.
There is nothing diagnostically similar about these six patients, yet they all have “15” GAF.
This confusing mix of three dimensions into a single number ["15" as opposed to "16"] implies an exactness that is false.
The multiaxial system unnecessarily separates our diagnosing from the rest of medicine [how many of us use the multiaxial system when communicating with a surgeon?]
Axis V reflects poorly on the reliability of psychiatry: It is very common for a hospital to have a rule that Axis V sore is always to be "below 40,"-- some the rule is "below 30."
GENERALLY, DSM'S MULTIAXIAL SYSTEM SEPARATED PSYCHIATRY FROM MEDICINE.
Below my name, some thoughts on this year's American Psychiatric Association election.
A Brent James, MD, summarizing the challenge in reducing billions in waste in US healthcare system: "One person's waste is another person's income" [Managed Care, this month].
At a meeting last night discussing lurasidone, I was left with several thoughts: a] to reduce side effects, probably best to give lurasidone at the evening meal; b] Unlike other antipsychotics, pregnancy risk status of Category B; c] has no QTc warning; d] probably joins aripiprazole, fluphenazine, haloperidol, loxapine, trifluoperazine, and ziprasidone in not causing a significant weight gain -- in comparison to other antipsychotics.
As to treatment of panic disorder, a review article concludes: "More than 25 years after the first report of efficacy in Panic Disorder in 1984, clonazepam, alone or combined with selective serotonin reuptake inhibitors (SSRIs) and/or behavioral therapy, remains an important therapeutic modality for the management of Panic Disorder. [In Current Drug Targets, 13 Feb 2013]
To help prevent autism, women, who are planning to go off THE pill, should consider replacing THE pill with a folic acid pill [JAMA 13 Feb 2013].
As to social anxiety disorder (SAD), a review concluded [International Journal of Neuropsychopharmacology, 28 Jan 2013]:
1] SSRIs and venlafaxine should be considered the first-line treatment for most patients.
2] SSRI non-responders may benefit from augmentation with benzodiazepines or gabapentin or from switching to monoamine oxidase inhibitors, reversible inhibitors of monoamine oxidase A, benzodiazepines or gabapentin.
3] CBT is a well-established alternative first line therapy that may also be a helpful adjunct in non-responders to pharmacological treatment of SAD
In last December's BJP, two articles that could be summarized as: Is there too much clozapine hesitation? One article found an average of four years before clozapine was initiated. Actually, the study had a four-year cut off. One can guess that in some settings the average number of years before beginning clozapine is >4 years. Off-label uses of meds are often begun before using the on-label clozapine.
FSI clinic, featured recently in the Post for its efforts to broaden its services, is looking for:
1. a child and adolescent psychiatrist to provide diagnostic evaluation and medication management services at its OMHC in Gaithersburg. Spanish speaking preferred but not required. (20 hours/ week).
2. an adult psychiatrist to provide diagnostic evaluation and medication management services at the Gude Men's Shelter in Rockville. (10 hours per week).
In this year's American Psychiatric Association elections, three of the eight nominations are residents of the County: Bob Ursano for President-elect, Brian Crowley for Trustee of Area III [Washington, Maryland, NJ, Delaware, and Pennsylvania], and me for Secretary. Brian won, Bob and I lost. Too bad Bob lost. He would make a great APA President.
I'm OK with losing. Since the 1970s, longer than anyone, I've been helping to set the APA agenda. The opportunity to continue that does not change, as setting the agenda goes with being the Washington Psychiatric Society Representative in the Assembly. It frees us up some in going against the grain, as the APA Secretary is expected to champion Board positions. So, be thinking of ways you would like to see the APA change or what you would like to see the APA champion as to national policies.
I'm reminded that almost my first day as Chief Psychiatrist, a dozen years ago, I was at a County Council hearing. Sitting next to me was someone I had never met, Diane Sterenbuch, a NAMI leader. After the usual pleasantries, she asked if I was a Member of the APA, I said, "Yes," and she said, "Well, I hate the APA." This surprised me, since, of course, I thought the APA only did wonderful things. She went on to say that her daughter had bipolar disorder, and she hated the APA because the name "Bipolar Disorder" was unfortunate and, even worse, personality disorders were placed on Axis II, which markedly limited access to treatment. Thus began many motions, "Action Papers," to the APA Assembly on DSM-5. Our fingerprints are all over DSM-5, including the abolishment of the Multiaxial System, but we were not able to get a name change for Borderline [because there was never any consensus on a substitute]. So, if any of you hate the APA, let me know as we will continue trying to set the agenda of the APA.
Time for pop quiz. This time: trivia. The Washington Physicians Directory lists thousands of local physicians. What is the most common last name? Hint: "Smith" comes in third.
The County is looking for a psychiatrist interested in a 13 hour/week contract. If interested, please call me at 240-777-3351.
From this month's Am J Geriatric Psychiatry on what seniors want as to psychotherapy:
1] The therapeutic relationship should be collaborative rather than reflective.
2] Treatment should acknowledge and integrate patient spirituality.
3] Participant recommendations included the importance of discussing shame associated with seeking treatment as an important engagement tool.
4] Treatment should focus on strategies to address problems commonly seen among older adults, for example social functioning, e.g., behavioral activation), cognitive skills, family therapy strategies, and financial counseling.
5] The treatment may need to be lengthened given the needs of the patients.
6] Participant choice in treatment approach (e.g., type, format, and length of treatment) should be considered.
Algorithms on treating schizophrenia usually have clozapine batting third. This month's AJP reviews that position and suggests that remain the guidance, especially that clozapine not bat first.
Two items from JAMA [6 Feb 2013}:
1] Two most commonly prescribed antipsychotics in nursing homes: quetiapine and risperidone.
2] Editorial reflecting on United States v Caronia, "Courts seemingly drift toward greater protection of commercial speech at the expose of rigorous science directly threatens the FDA's standing as the nation's arbiter of which drugs are safe and effective." This may also loosen up what Pharm company reps can talk to us about.
A number of us questioned whether the Maryland's Medicaid, under parity, could prohibit the use of 99201-99205 when billing for a new patient. On 4 Feb 2013, the decision was reversed. One can now use those four codes with Medicaid patients.
There are some new parts of DSM-5 that you may be able to use now if you are in a setting that does not limit which parts of ICD-9-CM you can use. We had suggested that "293.89 Catatonic Disorder in Conditions Classified Elsewhere" be added to DSM-5 so that one would have a codable disorder regardless of what other Dx the patient might have. However, we were not sure the Feds would approve. Darrel Regier, co-chair of DSM-5, even though super busy with the thousand of things needed to wrap up DSM-5, persuaded the Feds this month to accept this concept. So, if the pt has catatonia associated with a substance, a medical condition, whatever, and you want to see the catatonia recognized and coded, you can add "293.89 Catatonic Disorder in Conditions Classified Elsewhere" now without waiting for DSM-5.
For those preparing for Boards, we have updated our questions on Eating Disorders at RogerPeele.com:
DSM-I [1952] and DSM-II [1968] had what are called "prototype matching," like Merck manual and other medical texts, that is, a description of the typical disorder. Because reliability was so poor with DSM-II, the APA replaced prototype matching with Criteria Sets in DSM-III, DSM-IIIR, DSM-IV, and DSM-5. The ICDs have had no effort to define its entities, but there is talk of ICD-11-CM [due 2015 or so] having prototype matching for all entities. If this happens, APA may follow suit. In this month's JAMA Psychiatry, two articles on prototype matching suggesting that going back to prototype matching might be done in such a way as to improve reliability.
If needing to reach the state's insurance office, the address is: Mary.Kwei@maryland.gov.
About fifty years ago, J. F. Kennedy's administration called for the creation of 2000 CMHCs in this country. NIMH's model CMHC was created at St Es [then part of NIMH] for Anacostia. Key to it being a model was 1] Taking full responsibility for the patient regardless of need; 2] Pouring St. Es considerable into Anacostia. Last week, a proposal before the Senate calling for 2,000 Community Behavioral Health Centers. Not clear if they would be responsible regardless of the patient's needs. Symbolic of the lack of any agent feeling totally responsible in today's style was an article over the weekend in the NY Times about a new law specialty, a lawyer who sees her role as coordinating and obtaining all of the patient's needs.
Patient to psychiatrist: "I don't mind the voices themselves, Doctor. It's the Jersey accents that are driving me nuts." [The New Yorker, 4 Feb 2013]
With the 15 Feb in mind, this is the time of the year when journals like to publish a study on chocolate. From this month's J Psychopharmacology: a study found cocoa polyphenols did not change cognition or mood, but did improve self–rated calmness and contentedness relative to placebo. For those who "know" that chocolate improves their mood, cognition, and cardiovascular health, they can note this study was only for 30 days. Anyway, wish everyone a contented 15th.
Roger
As for question on last name: Lee - 82. Patel - 49. Smith 47.
Today, Robert J. Ursano gave another of his magnificent reviews of mental trauma and stress. A few notes:
For the initial approach to someone traumatized, Psychological First Aid, not debriefing, is recommended. An excellent summary of Psychological First Aid.
Hard to say exactly how successful preventive measures are since most people will eventually see a resolution of PTSD signs and symptoms CBT, especially prolonged exposure, is recommended. As to EMDR, not clear that it achieves more than CBT. Virtual reality is effective -- and expensive. Psychodynamic therapy can be helpful with allied issues that arise.Benzodiazepines are usually not helpful. There has been one major study to suggest they are harmful for the mentally traumatized.
SSRIs are useful, but are not as winning with PTSD associated with repeated mental trauma, such as in the military. Prazosin, while the focus over the years has been on its reduction of nightmares, it is now showing more general reduction of PTSD signs [see JAMA 23-30 2013, page 331]. Begin with low dose.
We see reports almost daily of the increased rate of suicide in the military. True, but the military used to have a very low rate. Now the rate is the same as the rest of the population. One cannot predict suicide, although some factors suggest an increased risk, such as the larger the number of number of psychiatric disorders, the more the risk.
Concepts of PTSD that can lead to specific therapeutic emphasis [some overlap]:
1] The patient has an inability to "digest" early stress symptoms, e.g., impaired ability to return to prior state.
2] Altered "set point" as to reactivity
3] The glue that makes the symptoms stay or cluster together. Can focus on the glue lead to reversal of all the signs?
4] Conceptualize as a disorder of not being able to forget trauma experience.
5] Moral issue for some in the military of not being able accept being party to killing. Associated with this thought is a finding that people with Antisocial Personality Disorder seem less vulnerable to PTSD.
6] PTSD is like an autoimmune disorder.
7] Traumatized may avoid using "natural therapists," such as family members.
PTSD potential may be dormant for decades, then arise when the person develops a life-threatening illness such as cancer. Also, may erupt with the development of dementia. [I remember a case of a WW-II submarine captain whose showed no signs of the WW-II traumas and tortures, developed Alzheimer's and spent his last months, sadly, reliving those traumas and tortures.]
DSM-5 will place the trauma and stress related Disorders into its own chapter.
The national fee schedule regulations and files are here.
CMS lets you look up a specific code here.
---
Last Thursday's, NY Times, "Grief Over New Depression Diagnosis." The big fuss is about paragraph "F" of Major Depressive episode, DSM-IV-TR.age 356: "The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persists for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation." DSM-5 will remove paragraph F. This will lead, some say to medicating normal grief. Maybe not. First, this article begins saying that the DSM is "the bible of psychiatric disorders." While clinicians respect the DSM, only researchers worship it. If the clinician feels that the pt's depression should be treated, paragraph F has not been stopping them. They can note one of the signs listed at the end of paragraph F, or select Depressive Disorder NOS [code 311]. We might be better served if the focus was not on over-diagnosing but on under-utilizing of psychotherapies for these depressed folks -- often a better choice than a medication.
J Clin Psychiatry [Dec 2012]:
1] Asenapine, 5 - 10 mg/d, for acute schizophrenia, did better than placebo in four of five studies and no better than ten other antipsychotics.
2] Ziprasidone, doses < 120 mg/d, monotherapy for MDD, did no better than placebo.
JAMA, 9 Jan 2013:
1] Clinical work results in hours of physical inactivity. Partially for their own health and partially as a good example for everyone else, clinicians should consider adding 3-5 or more minutes moderate to vigorous physical activity/d to their schedule. Also, a report that such will increase memory.
2] An article suggesting about a dozen situations when the physicians should obtain an interpreter included the following statement: Interpreters should be used when psychosocial issues predominate, including all encounters for mental or behavioral health or substance abuse." So, you do not need to read the whole list.
The National Psychologists, Jan-Feb 2013 quotes someone, reflecting on the change from ICD-9-CM to ICD-10-CM, "At this point, we don't know how similar ICD-10-CM will be to DSM-5 codes." We can relieve their anxiety. Part of the answer is to know that ICD-10-CM [due for implementation October, 2014] is 99+% the same as DSM-IV-TR. When you buy DSM-5, you will find it will have both ICD-9-CM and ICD-10--CM codes for every Disorder in the book.
JAMA: 2 Jan 2013: Among women with singleton births in Nordic countries, no significant association was found between use of SSRIs during pregnancy and risk of stillbirth, neonatal mortality, or postneonatal mortality.
Clinicians expect to look for empirical evidence to guide their actions. Policy makers are not so limited, exemplified by the recent decisions to penalize hospitals for readmissions within 30 days, which "does not have a clear biological, clinical, or therapeutic evidence base" [JAMA 23/30 2013]. Further, "the focus on the financial may distort incentives, care, and ultimately outcomes by diminishing efforts to improve intermediate- and long-term outcomes." The focus of this CMS policy, I gather, will not pertain to psychiatric disorders until after 2015, if then?
Next Sunday, rather than talk about sweeps, traps, counters, bootlegs, flat routes, and so forth, you can be the death of the Super Bowl party and talk about our ability to identify increased trauma in the brain resulting from head trauma while the person is still alive using 2-(1-{6-[(2-[F-18]fluoroethyl)(methyl)amino]-2-naphthyl}ethylidene)malononitrile positron emission tomography. [Am J Geriatric Psychiatry, Feb 2013.]
Note that the APA site has a new-patient form and a progress-note form that you might want to modify and improve with:
1] spacing that is more consistent with your practice,
2] with checklist boxes to shorten the time needed to complete the form, and
3] with removal of the multiaxial system.
Maryland Medicaid, for the moment, is not allowing use of some codes [99202/99203/99204/99205 and others]. The degree to which they can so "discriminate" may be challenged.
A common question: What does “location” mean. Apparently I was wrong to put “superego.” “Location” for psychiatrists refers to behavior or emotions.
We frequently hear that "time is not a factor" when deciding whether to use outpatient codes 99212, 99213, 99214, or 99215. That may not the whole story. I gather Maryland Medicaid, handled by Value Options, for example, if the session includes more than 50% of consultation and coordination activity, still face-to-face with the pt, then, you may want to see if the following applies in your setting:
99212 - 10 minutes [= <13 minutes]
99213 - 15 minutes [= >13 minutes and <20 minutes]
99214 - 25 minutes [= >20 minutes and <33 minutes]
99215 - 40 minutes [= >33 minutes]
If going this route, then time, not "elements," "bullets," and so forth is the determining factor
I have heard that if you go this route, you cannot add psychotherapy.
5. Importance of adherence to chosen management [treatment] options
6. Assessing and addressing risk factors
7. Patient and family education
If COMAR regulations apply in your setting, I am under the impression progress notes need to include:
(a) The date;
(b) The start time and either the duration or the end time;
(c) The individual's chief medical complaint or reason for the visit;
(d) The individual's mental status;
(e) The delivery of services specified by the ITP;
(f) A brief description of the service provided;
(g) The plan for changes in treatment, if any;
(h) The individual's progress toward treatment goals; and
(i) A legible signature and printed or typed name of the licensed mental health professional providing care, with the appropriate title.
I am not authoritative on CPT issues, but did want to bring up some issues that may be helpful to you as to questions you may want to ask in your setting.
On the issue of guns, the following from one of APA’s most prominent leaders, Paul Appelbaum: “Substantial research shows that the vast majority of people with serious mental illnesses never act violently, and the vast majority of violent crimes—96% by the best available estimate—are not perpetrated by persons with mental disorders.” So, that gives psychiatrists, as psychiatrists, 4% of the problem to address as "experts." [MedicalSchool and Psychiatric residency training did not leave me authoritative on guns, the law, criminals, and so forth.]
Below my name a draft of what is close to the wording of a new entity, Disruptive Mood Dysregulation Disorder, which will appear in DSM-5: It should decrease the use of some other diagnoses in children: Bipolar I, Bipolar II and NOS Disorders in children. As this Disorder becomes recognized, hopefully, consensus guidelines that point out that the first-line treatment for preschool disruptive behavior are psychosocial approaches, not medications, will be better known [see this month’s J AACAP, p 26 – 36].
In obtaining a history of past response to antidepressive treatments from a patient, a study suggesting that what we hear “poorly agrees with data from that patient’s medical record.” Best to get the record [J Clin Psychiatry, December 2012].
A meta-analysis of use of meds for acute mania concluded that the following agents were more effective than placebo for mania: aripiprazole, asenapine, carbamazepine, haloperidol, lithium, olanzapine, paliperidone, quetiapine, risperidone, tamoxifen, valproate, and ziprasidone. The report concluded that antipsychotic drugs were significantly more effective than mood stabilizers [Note that this is focused on the acute condition]. Risperidone, olanzapine, and haloperidol were particularly efficacious. [Psych Times, December, 2012] Not clear to me why the eight first generation antipsychotics FDA approved for mania were not included.
On this topic of first generation [FGA] v. second generation antipsychotics [SGA], the British Ass for Psychopharmacology concluded “No double-blind trial comparing an SGA with an FGA in the acute treatment of first-episode schizophrenia has shown an efficacy advantage for the SGA, with the single exception of a head-to-head, first-line treatment trial of clozapine versus chlorpromazine conducted in China." [J Psychopharmacology 2011:25(5):267-620.]
From the NY Times on the 10th: “The conversion to electronic health records has failed so far to produce the hoped-for savings in health care costs and has had mixed results, at best, in improving efficiency and patient care, according to a new analysis by the influential RAND Corporation.”
Memantine has been used off-label to treat frontotemporal lobar degeneration (FTD). A study supported by the marketers of memantine [Forrest] concluded that “Memantine treatment showed no benefit in patients with FTD.”
At last month’s meeting of Society of Neuroscience, two animal studies suggested that the benefit of exercise on memory, more specifically the increased size of the hippocampus, is rapidly lost when the exercise is discontinued.
Family Services Inc. has need for psychiatry in its OutpatientMentalHealthCenter and in satellite sites in Germantown,Greenbelt and Rockville. Looking for both adult and child psychiatrists. Spanish speaking a plus. If interested contact 301-840-3203
Roger
Disruptive Mood Dysregulation Disorder:
A. The disorder is characterized by severe recurrent temper outbursts that are grossly out of proportion in intensity or duration to the situation.
The temper outbursts are manifest verbally and/or behaviorally, such as in the form of verbal rages or physical aggression towards people or property.
The temper outbursts are inconsistent with developmental level.
B. Frequency: The temper outbursts occur, on average, three or more times per week.
C. Mood between temper outbursts:
Nearly every day, most of the day, the mood between temper outbursts is persistently irritable or angry.
The irritable or angry mood is observable by others (e.g., parents, teachers, peers).
D. Duration: Criteria A-C has been present for 12 or more months. Throughout that time, the person has not had 3 or more consecutive months when they were without the symptoms of Criteria A-C.
The disorder must also be present in 2 or more settings (just like ADHD), and the symptoms must appear before age10.
[Keep in mind that the final decisions as to the content of DSM-5 are confidential, that the above is from a draft promulgated a year ago.]
Some of you have pointed out that Medicaid, Value Options, will not pay for New Pt codes, 99201-99205. I asked why, and got the following answer from Helen Lann, MD, of Value Option: Value Options decided not to include "all the 'new patient' codes as they only complicated the service class code grid and made it more confusing and the new patient E/M rates would pay less than the 90792 anyway. That is why they are not included."
If billing for 90792, Beth Morrison has pointed out that the easier-to-document 90791 may pay more, so check to see which pays what before selecting.
A study with an 2.88 million of whom 270,000 died, concluded that there is a need to reconsidered what is a healthy weight. Study found a BMIbetween 30 and 35, "obese," lived as long or longer than other BMI categories. Only BMI > 35 died younger than the other levels. [JAMA 2 Jan 2013]
There was no significant association between use of SSRI during pregnancy and risk of stillbirth, neonatal death, or postnatal death, according to a study of nearly 30,000 women [JAMA 2 Jan 2013].
Another PTSD theory [NY Times, page D2, 25 DEC 2012]: Whether the individual develops PTSD is a function of the presence of social supports, that the posttraumatic mental health is dependent not on the exposure of trauma per se, but how their families and community receive them. Remember, theory. Not the basis for stigmatizing the familles of people with PTSD.
The Washington POST had a long article on pharmaceutical company impact on DSM-5. As one who was part of the DSM-5 process at several hurdles and as one of APA guards at the gate of APA's conflict of interest process, a thought. Missing from this and other critiques is discussion of the NOS dx. DSM-IV's NOSs are so broad that there are virtually no boundaries. For example, 313.9 "This category is a residual category for Disorders with onset in infancy, childhood, or adolescence that do not meet criteria for any specific disorder in this Classification." WPS had a motion passed by the APA's governance to tighten that up considerably, but it was not done. Every time I voted for a new dx entity for DSM-5, I thought that it should decrease the use of NOS.
While we are on this topic, a chance to prepare for DSM-5: There will be no NOS in DSM-5. Instead, DSM-5 will have "Other" for recognized syndromes for which there is no specific code, and "Unspecified" for when the signs and symptoms do not fit a syndrome. Both will require clinically significant distress or disability. Usually "Other" will have an "8," that is, xxx.x8. Unspecified will usually have a "9," e.g., xxx.x9.
From December's MANAGED CARE: Carving mental health benefits from the rest of medicine takes "credit" for the reduction in the proportion of the health care dollar being available in this country for mental health services, 9.3% in 1986 to 7.3% in 2005. The article wondered if a carved out approach would survive the need in the future to achieve integration of health care, made difficult with HIPAA rules impeding sharing of information.
Some have asked for the specific APA wording on the ethics of publicly pronouncing diagnoses of those who one has not examined:
"On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement."
Reflecting on recent mass-murder [NEJM 26Dec2012]: "
"We pore over the details, searching for the clues that will bring order to chaos and help us predict and prevent the next one. But these catastrophes are all different. We have found to our dismay that prediction is somewhere between difficult and impossible. Tailored interventions, designed for specific circumstances, will have little effect. We need to take a broader approach." For the author's proposals, see:http://www.nejm.org/doi/full/10.1056/NEJMp1215491
Some data:
Rate of drug-induced deaths/100,000/y [2007-2009]:
National -- 12.6; Maryland -- 13.4; MontgomeryCounty -- 5.
Rate of suicides pere 100,000 [2007-2009]:
National -- 11.3; Maryland -- 9.6; MontgomeryCounty -- 7.1
The County is recruiting for a psychiatrist [13 hours/week] for its methadone-maintenance program [240 777 3351].
Family Services [301 840 3203] is recruiting for a Spanish-Speaking psychiatrist.
