Open Source-Please Comment

I have an idea, in very rudimentary form, and I'd like to get peoples' opinions on it.

But first, an amusing anecdote:

The attending who taught me ECT was a character. He'd been doing ECT forever, and his approach was quite old-school. When the patient started to seize, as noted by the twitching toe, he would determine the length of the seizure by counting, 1-Mississippi, 2-Mississippi, 3 Mississippi...
One time, I suggested we look at the clock, and he said, "No, no, this is better." 1-Mississippi was his definition of clinical rigor. Clearly, this was not science.

I read somewhere, some time ago, that the DSM (3?) committee voted on the criteria for MDD. "Those in favor of worthlessness/guilt? Approved! Those in favor of helplessness/hopelessness? Not approved!"

Clearly, this was not science.

But here's the interesting part. How was it determined that 126 was the cutoff for diabetes? I'm not going to look up the history, but I imagine it started with the idea that diabetes was a disease, whose symptoms included ketosis, polyuria, polyphagia, polydypsia, etc. And after seeing many patients with this condition, some clever person figured out that it had something to do with glucose. And later, they realized that if a patient's glucose level is too high, that patient has diabetes. And then "too high" needed to be defined. Presumably, they took a lot of patients who had known diabetes and compared them with normal controls by testing glucose levels. And eventually, they figured out that most patients with diabetes had glucose levels > 126, and most patients without diabetes had levels < 126.

That is science. And it involved a lot of data over a long period of time. Now, granted, they had a test they were looking at-plasma glucose concentration. And there are no convenient lab tests in psychiatry. But there is data.

Not the data you get from a drug-company-sponsored study, where fancy statisticians are hired to produce any desired reality (see, for example, this post). And not the data you get from a 20 person committee voting on a diagnosis.

But what if it was a 200 person committee? Or 2000? Or 20,000? Imagine 20,000 mental health practitioners chiming in on which symptoms they've seen the most. Or which meds they've found most effective. Or least. Or what type of therapy works best for what type of patient. One anecdote is meaningless. But 20,000 anecdotes? Not so meaningless.

I'm talking about the power of the internet. There was a time when the largest number of clinicians you could get in one place was at an APA meeting. Or a survey sent out by snail mail. Now, there's worldwide access at all times. Who needs the DSM when there's the possibility of open source psychiatric data and unlimited discussion?

Would this do anything to determine etiology? No. Not in and of itself, anyway. Would it be valid or accurate? Who knows? People are skeptical about Wikipedia, but is there any more cause for skepticism there than in an old-fashioned encyclopedia article written by one biased individual? Or one closeted committee?

Facebook changed the world by recognizing that a huge collection of connected individuals is a very powerful thing. Why can't we make that idea work to our patients' benefits?

Please comment on this post. I'd like to get a sense of what people imagine this could be like.

WHO-Hoo!

Here's some good news for anyone who doesn't want to buy, read,
or use the DSM-5.

The World Health Organizatio (WHO) provides free online ICD-10 access, and free online ICD-10 training. I worked through most of the training, and it's a bit dull, but pretty intuitive.

Fittingly, Mental and Behavioral Disorders are in chapter V.

Here's a peak at how depression is described, ICD-10 style:

Depressive episode

In typical mild, moderate, or severe depressive episodes, the patient suffers from lowering of mood, reduction of energy, and decrease in activity. Capacity for enjoyment, interest, and concentration is reduced, and marked tiredness after even minimum effort is common. Sleep is usually disturbed and appetite diminished. Self-esteem and self-confidence are almost always reduced and, even in the mild form, some ideas of guilt or worthlessness are often present. The lowered mood varies little from day to day, is unresponsive to circumstances and may be accompanied by so-called "somatic" symptoms, such as loss of interest and pleasurable feelings, waking in the morning several hours before the usual time, depression worst in the morning, marked psychomotor retardation, agitation, loss of appetite, weight loss, and loss of libido. Depending upon the number and severity of the symptoms, a depressive episode may be specified as mild, moderate or severe.

Incl.:

single episodes of:

• depressive reaction
• psychogenic depression
• reactive depression

Excl.:

adjustment disorder (F43.2)

recurrent depressive disorder (F33.-)

when associated with conduct disorders in F91.- (F92.0)

F32.0Mild depressive episode

Two or three of the above symptoms are usually present. The patient is usually distressed by these but will probably be able to continue with most activities.

F32.1Moderate depressive episode

Four or more of the above symptoms are usually present and the patient is likely to have great difficulty in continuing with ordinary activities.

F32.2Severe depressive episode without psychotic symptoms

An episode of depression in which several of the above symptoms are marked and distressing, typically loss of self-esteem and ideas of worthlessness or guilt. Suicidal thoughts and acts are common and a number of "somatic" symptoms are usually present.

Agitated depression Major depression Vital depression

single episode without psychotic symptoms

Who-Hoo! No more Chinese menu!

ICD-10 codes are very different from ICD-9 codes, which are structured like DSM codes. Will insurance companies accept them? Looks like they will, starting October 1, 2014. Until then, ICD-9 will have to do.

Thanks, WHO.

E-Rx F/U and Confession

This is a practical follow-up to my recent post, Erx Me.

I went through the E-Rx validation process at Practice Fusion. It involved submitting a very simple form, along with my medical license and government issued ID. The instructions were a little confusing, because it asked for a valid medical license, so I wasn't sure if that meant a copy of the license, or the registration, which has the valid dates. I live-chatted with them, and they were immediately responsive, and told me I could use either, and they would verify the dates.

It was a bit difficult to find the right place to submit it, but I got there, eventually. I apologize but I don't remember exactly how I found it.

The instructions said it could take 7 business days to complete the validation process, or more if they were particularly busy. I got confirmation the same day.

So, thus far, overall, Yay! for Practice Fusion.


I also tried to register for I-STOP. But I have a confession to make. I terminated my membership in the APA a year ago. I felt that they were just extorting money for CME, and that my money was better spent on something like UpToDate. Also, they implemented the MOC PIP program, which I find unacceptable.

But I still seem to get emails from the NYSPA, which is how I found out about I-STOP. Of course, since my membership expired, I can't log in. So I wasn't able to register through the NYSPA site for I-STOP.

Well, after some fumpfing around online and fuming at the idea that I might have to rejoin the APA for something that is required by law, I discovered that I didn't need to register through their site. In fact, I didn't need to register at all, since the Prescription Monitoring Program can be accessed through the NYS DOH portal. And I already have an account there, since that's how I order my prescriptions.

The instructions  for finding it were moderately helpful. You log in, click on the "Applications" tab at the top, click on the letter "P", and then scroll down to the PMP Registry. That part was easy, once I found the right instructions. As a bonus, the link to order new prescription pads is right below it.

I was then instructed to click on the green "+" sign to the right of the link, to add this to my favorites. I did so, several times, and my favorites still says it has nothing in it.

Summary: It's pretty easy to get started with E-prescribing through Practice Fusion, and you don't need to register for the Rx monitoring program through NYSPA.

Just FYI.

Erx Me

In case you thought you were done with big practice changes, s/p CPT, DSM-5, think again.

"Starting August 27, 2013, all physicians who prescribe Schedule II, III and IV controlled substances will be required to consult a new online state registry designed to track the prescription and dispensing of controlled substances."

This is from the NYSPA's comment on the new I-STOP law.

Here's a good I-STOP resource, from the Medical Society of the State of NY.

From what I can tell, starting on August 27th of this year, when we write prescriptions for controlled substances, we will have to open up our laptops or ipads or whatever, right there with the patient, and check that the patient is not up to any funny business with his meds.

I'm assuming this because of the phrase, "real time", which is supposed to be defined in regulation.

So, here you are, in your office, and you look up the patient on the registry, and you say, "Mr. Patient, it seems you've been diverting your meds, so I can't write that prescription for you. Have a nice day."

I don't know. The level of monitoring is getting out of control. It's like legislative OCD. And it carries such righteous indignation. We're going to purge the country of the evil of prescription drug abuse. Yeah, okay. It's a problem. But it doesn't have to be the Spanish Inquisition.

And it's one more way the government is insinuating itself into the room with the patient. Others include implying the psychiatrist is not doing a good job unless the patient is filling out checklists, and requiring patient reviews (see this post).

But that's not all. Starting on December 31, 2014, ALL prescriptions will need to be submitted electronically.  I was trying to figure out how to implement this, and I know, from risk management classes, that electronic medical records are a no-no, since, even if you can guarantee security (and really, you never can), if the data is stored in the cloud, you don't know who owns it. So I figured there're going to be some problems with e-rx's, and I called my carrier to find out if they have any advice about potential pitfalls, etc. They didn't have a lot of information, but referred me to the AMA's website, for  A Clinician's Guide to Electronic Prescribing, which was actually not that easy to find through the site, and I ended up googling it.

What WAS relatively easy to find was their e-prescribing learning center, where you can learn about how great e-rx is, and how it will solve the age-old problem of illegible prescriptions. You can also learn about how much it will cost you to implement and maintain your e-rx system. In fact, it'll walk you through a series of questions to help you determine which system is best for your practice. And then it will give you a list of e-rx systems that meet your needs.

I tried it, and I answered all questions on the "no frills" end, i.e., I don't want any advanced features, I don't want an EMR to go with it, etc. It came up with 3 recommended systems:

Relayhealth Escript at $600, no demo available
Care360 Physician Portal 2008.3, at $240, no demo available, and
InfoScriber, version 115, at $600, no demo available

Now, I didn't try to look this up, but I'm willing to bet that the AMA has financial connections with all these systems, and any others it spits out. It certainly didn't refer me to Practice Fusion, which is free, comes with an, also free, EMR which you don't have to use if you don't want to, and is ranked #1 for both e-rx vendors, and EHR based e-rx vendors, by the Black Book Rankings.

Bottom line: I signed up for Practice Fusion (no, they're not paying me to write this), and I'm in the process of being verified for the e-rx (apparently, you have to do that). I'll let you know how it goes.

As I was writing this, it occurred to me that once we start e-prescribing controlled substances, we'll be taking diversion of these substances out of the hands of individuals who have to hustle to get hold of a one-month supply of meds, and placing it in the hands of anyone savvy enough to hack the system. Who could do that? Oh, I don't know, maybe a large scale crime organization, or your average computer science major at MIT. Goodbye, diversion in dribs and drabs, hello big-time diversion.

CPT-New and Improved?

In response to my recent CPT article, CPT: A Primer, in The Carlat Report, I received an email from Joel Shield, MD. I don't know Dr. Shield, but I want to share some of the content, and I have his permission to do so.

Dr. Shield writes about the real CPT coding, as opposed to what's being presented as CPT coding, which is really the Center for Medicare Services' (CMS) version, the version I've researched and written about because I didn't realize there was a difference.

What is the difference? Basically, the CMS version is a checklist, with, for example, 1-3 elements of HPI, at least 6 elements on exam, and 1 pertinent ROS for a 99213 (see my post).

But the version from the CPT 2013 manual is much more descriptive. You have to meet the same standard-providing enough information to qualify your coding, but it's much less of a checklist.

I'm not getting into too much detail because that might involve purchasing the manual so I could figure out what goes into it. Dr. Shield forwarded two articles he wrote up about the coding, and I'd like to include them, but I haven't figured out how to attach a pdf to a post. If anyone knows, by the way, please comment and tell me how.

However, a nice summary was included with the email I received:


In summary, the CPT manual and the CMS guidelines use the same categories for coding E&M services (the four levels of history, examination, and medical decision making), but differ significantly in some of the details of those categories (for example, the CMS guidelines specifying psychiatric, constitutional, and musculoskeletal parts of the psychiatric examination) and, most importantly, in adding a sub-basement level of very detailed requirements for what defines the levels of history, examination, and medical decision making. While the descriptions of the levels in the CPT manual are, in general terms, the same as those of CMS, because they are more descriptive they can be satisfied more flexibly and more easily. 

Now here's the rub: If you document more descriptively, you can be less freaked out about what goes into your documentation. You might even be able to write the kind of note you're accustomed to, one that has something to do with patient care. But, if you ever get audited, or need to justify your services to someone who may or may not have graduated from high school, someone who is simply going to count the number of bullet points you did or didn't include in your documentation, then you're better off having bullet points to be counted.

To be honest, I'm bugging out a little over all the recent changes. You need to bill differently, and learn how to bill differently. You need to diagnose differently, and learn how to diagnose differently. It's too much. I'd really like to get back to my day job.

Quick Link to Book Review

Here's a review of The Book of Woe: The DSM and the Unmaking of Psychiatry, by Gary Greenberg. For those who want more on the DSM-V saga.

The Other Winner

I haven't forgotten my promise to review the winners in my survey. Survey takers, god bless you, voted for chapter rearrangement as the change in DSM-5 that would do the most good. You can link to the full Table of Contents from here (sorry it's indirect).

Looking over the chapters there's really a lot to cover, especially if I'm trying to compare with DSM-4. So I thought I'd start with just the first clinical section in each.

DSM-5 begins with the general heading, Neurodevelopmental Disorders, and this section is broken down into subsections (which are further broken down). They are:

• Intellectual Disabilities
• Communication Disorders
• Autism Spectrum Disorder
• ADHD
• Specific Learning Disorder
• Motor Disorders
• Other 

The corresponding section of DSM-4 is called, Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence with these sections:

• Mental Retardation
• Learning Disorders
• Motor Skills Disorder
• Communication Disorders
• PDD
• ADHD
• Feeding and Eating Disorders of Infancy or Early Childhood
• Tic Disorders
• Elimination Disorders
• Other

I'm not sure which I prefer. In DSM-5, Tic Disorders are included under Motor Disorders, rather than having their own section as in DSM-4. Learning Disorders are broken down into specific disorders in DSM-4, while in DSM-5 they're not. And, of course, DSM-4 includes multiple Pervasive Developmental Disorders, where DSM-5 groups all under the heading of Autism Spectrum.

In addition, DSM-5 puts all feeding and eating disorders, regardless of developmental stage, into their own section, entitled, unsurprisingly, "Feeding and Eating Disorders", and this section occurs much later in the book. It's immediately followed by the Elimination Disorders section, which removes the implication of these as childhood disorders.

So it's looking like DSM-5 does more lumping, where DSM-4 did more splitting. But that's not entirely consistent.

And you have to admit, there's a nice logic to following the Eating chapter with the Elimination chapter.

One thing I do like about the chapter organization in DSM-5 is that, unlike DSM-4, Neurodevelopmental disorders, which are basically childhood disorders, are not followed immediately by delirium and dementia, disorders of old age.

I'll cover more in future posts because it's getting past my bedtime.

And In This Corner....

Get ready to rumble!

Meet the contender: Thomas Insel, MD of NIMH

And the reigning champion, David Kupfer, MD of the DSM-5

Dr. Insel comes out swinging with the Research Domain Criteria (RDoC), the project launched by NIMH "to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system."

And, wait for it, "..it is critical to realize that we cannot succeed if we use DSM categories as the 'gold standard'...The diagnostic system has to be based on the emerging research data, not on the current symptom-based categories."

Ooooh, low blow.

Now Dr. Kupfer counters with, "Efforts like the National Institute of Mental Health’s Research Domain Criteria (RDoC) are vital to the continued progress of our collective understanding of mental disorders. But they cannot serve us in the here and now, and they cannot supplant DSM-5. RDoC is a complementary endeavor to move us forward, and its results may someday culminate in the genetic and neuroscience breakthroughs that will revolutionize our field. In the meantime, should we merely hand patients another promissory note that something may happen sometime?"

Dr. Insel staggers backward into the ropes. He's covering up with his gloves. But wait, he shoves Dr. Kupfer away and pummels him with, "That is why NIMH will be re-orienting its research away from DSM categories. Going forward, we will be supporting research projects that look across current categories – or sub-divide current categories – to begin to develop a better system."

And Dr. Kupfer is down! The grant money gets 'em every time.


* I hope the Ali-Frazier image is old enough (1974) to be off copyright. If not, I'll promptly remove it, with my apologies.

Bereavement

Bereavement was the winner-the DSM-5 change that those who took my survey believe has the potential to do the most harm.

This feels especially relevant to me, since I lost a parent a couple months ago. (Life goes on, gotta keep blogging through).

To review, in DSM-4, Bereavement gets a V-code (other conditions that may be a focus of clinical attention): V62.82:

This category can be used when the focus of clinical attention is a reaction to the death of a loved one. As part of their reaction to the loss, some grieving individuals present with symptoms characteristic of a Major Depressive Episode (e.g., feelings of sadness and associated symptoms such as insomnia, poor appetite, and weight loss). The bereaved individual typically regards the depressed mood as "normal", although the person may seek professional help for relief of associated symptoms such as insomnia or anorexia. The duration and expression of "normal" bereavement vary considerably among different cultural groups The diagnosis of Major Depressive Disorder is generally not given unless the symptoms are still present 2 months after the loss. However, the presence of certain symptoms that are not characteristic of a "normal" grief reaction may be helpful in differentiating bereavement from a Major Depressive Episode. these include 1) guilt about things other than actions taken or not taken by the survivor at the time of death; 2) thoughts of death other than the survivor feeling that he or she would be better off dead or should have died with the deceased person; 3) morbid preoccupation with worthlessness; 4) marked psychomotor retardation; 5) prolonged and marked functional impairment; and 6) hallucinatory experiences other than thinking that he or she hears the voice of, or transiently sees the image of, the deceased person. (DSM-4 TR Desk Reference, Pp. 311-12).

And don't forget, in the DSM-4 definition of a Major Depressive Episode (ibid. p. 169), criterion E specifies that the symptoms are not better accounted for by Bereavement:

I.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked funcional impairment, ... worthlessness, suicidal ideation, psycho(sis), or psychomotor retardation. 

So, same as above.

Considering this in light of the imminent publication of DSM-5 (incidentally, I thought it would be published on the 3rd, but Amazon doesn't have it til the 27th, B&N the 22nd ), it doesn't seem like that much of an improvement.  Two months is not a very long time following a loss. And functional impairment and psychomotor retardation sound like the kinds of things that might linger for a while.

While I'm trying to make the argument that even DSM-4 pathologized grief, I think I'm only succeeding in making the argument that grief, or bereavement, may be hard to differentiate from Major Depression. And this, I believe, is the force behind the removal of the exclusion criterion.

Reading up on this topic just made me more confused than I already was. So I'll try to stick to my basic questions, and share with you what I've learned so far.

1. How can I tell if my patient is depressed, or simply grieving following a loss?
2. How important is the time factor, (i.e. 2 months)?


Since the road to understanding should be paved with clarity, I think we need some working definitions. These are from:

Zisook, S; Shear, K; Grief and bereavement: what psychiatrists need to know; World Psychiatry. 2009 June; 8(2): 67–74.

Bereavement is the actual loss-the death of a loved one. Grief is the emotional reaction to the death. And mourning describes some of the typical behaviors associated with the death, like funerals or religious practices.

The same paper also differentiated between Uncomplicated Grief, Complicated Grief, and Grief-Related Major Depression.

For me, these are useful concepts, because they point to the difference between what is and isn't expectable following a bereavement. You can read the specifics in the paper, but the idea is that, in uncomplicated grief, there is an intense, acute phase, followed by a resolution into a less intense phase, "integrated grief". In complicated grief, seen in 10% of grieving individuals, the transition to an integrated state never occurs. And grief-related major depression is neither uncomplicated nor complicated grief. It is a major depressive episode that occurs following a bereavement.

Now the question is, if a patient meets criteria for a major depressive episode within 2 months of a death, is this really grief disguised as depression, is it depression in addition to grief, or is it depression brought on by the loss that caused the grief, or by the grief, itself?

According to the Zisook paper, between 24% and 42% of recently bereaved subjects met criteria for a major depressive episode within the first 2 months following a bereavement. And 16% were still depressed at 12 or 13 months (depending on the study). Most importantly, the best predictor for depression at 13 months was depression at 1 or 2 months. A past history of major depression also predicted depression at 1 year following bereavement. And bereaved persons are also at risk for lingering subsyndromal depressive symptoms. In addition, bereavement, itself, can precipitate a depressive episode.

This paper, along with others by the same author(s) concludes that bereavement related depression is similar to non-bereavement related depression, which implies the removal of the bereavement exclusion is valid: If it looks like depression, then it IS depression, and should be treated as such.

Well, maybe.

Another paper,
Mojtabai, R; Bereavement-Related Depressive Episodes Characteristics, 3-Year Course, and Implications for the DSM-5; Arch Gen Psychiatry. 2011;68(9):920-928, has a different take. I found this paper clearer and more convincing than the previous one, although this may not be evident from my description (read 'em!).



This study looked at a very large sample and compared the characteristics and outcomes of 5 different groups: 1. Those with a single, brief (<2 months) episode of depression following a bereavement; 2. Those with a single, brief episode of depression not following a bereavement;
3. Those with a single, non-brief (> 2 months) episode; 4. Those with recurrent depressive episodes; and 5. Those with no lifetime history of depression.

In terms of baseline characteristics, group 1 (single brief episode following bereavement) was more likely than group 2 to be 50 or older and to be non-Hispanic Black. Group 1 was less likely than group 2 to have impairment in functioning, to have onset in their 20's, to have a co-morbid anxiety disorder, to have sought treatment, or to have been prescribed medication for depression.

Compared with group 4, group 1 was less likely to have a family history of depression, comorbid alcohol dependence, and onset before the age of 20 years.

In terms of symptom profiles, group 1 was less likely than group 2 to experience feelings of worthlessness, suicidal ideations, increased sleep, or fatigue.

And as far as follow up goes, "Participants with bereavement-related, single, brief depressive episodes were not more likely than participants without a lifetime history of depression at baseline to experience a depressive episode during the 3-year follow-up... However, participants with bereavement-unrelated, single, brief depressive episodes had an elevated risk of experiencing a depressive episode at follow-up compared with participants without a history of depression..., and compared with those with bereavement-related depressive episodes (14.7% vs 8.2%, adjusted odds ratio [AOR], 1.88; 95% CI, 1.05-3.38; P = .04). Participants with single, nonbrief depressive episodes also had an increased risk of new depressive episodes in follow-up compared with participants with bereavement-related, single, brief depressive episodes..., as did participants with recurrent depressive episodes compared with those with bereavement-related, single, brief depressive episodes..."

There's a whole lot more, obviously, but to summarize what I've learned so far:

Post-bereavement, it's appropriate to assess the grieving patient for depression, in addition to, or as a result of, or instead of, grief. Within the first 2 months, if the patient does not have 5 of the 9 criteria for a major depressive episode, then the patient is not experiencing a major depressive episode, and is assumed to be grieving.

What if the patient does have 5 of the 9 criteria? It depends who you ask:

• According to DSM-4, if less than 2 months have passed since the death, AND there is no evidence of marked funcional impairment, ... worthlessness, suicidal ideation, psycho(sis), or psychomotor retardation, then the patient is not depressed, but rather grieving. But if more than 2 months have passed, OR any of these symptoms is present, regardless of the time frame, then the patient is depressed.
• According to DSM-5, the patient is depressed.
• According to the Zisook paper, the patient should probably be treated for depression, since post-bereavement depression is similar to bereavement unrelated depression.
• According to the Mojtabai paper, the patient is likely to fare better than one with a bereavement-unrelated depression, with fewer sequelae and less severity, and this should be factored into the decision to treat.

I am now more educated and less certain about this topic than I was when I started to research it. One question I haven't really taken up is, why 2 months? Why not 2 weeks, if we're talking about criteria for major depression? Or longer than 2 months? 

What will be the effect of the removal of the bereavement exclusion? Will fewer treatable depressions be missed? Will morbidity increase from treating conditions that don't require treatment, or from pathologizing normal processes?
The answer is the same as the solution to grief, itself. To quote Viola from Twelfth Night:

O time! thou must untangle this, not I;

It is too hard a knot for me to untie!