Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Monday, March 30, 2015

Analytic Evidence

One of my goals, or maybe wishes, in writing this blog, is to educate a wider audience about psychoanalysis. Let's face it, analysis is, at best, passe. Mostly it's dissed. After all, everyone "knows" there's no evidence that analysis works, but there's lots of evidence that CBT works, so why spend all that time and money in analysis when you could be in and out in 30 sessions?

Just see this article in the NY Times:

As Jeffrey A. Lieberman, chairman of psychiatry at the Columbia University College of Physicians and Surgeons, makes clear in his chatty, expert, sometimes scathing but ultimately upbeat account of the history of psychiatry, the evidence, quite simply, doesn’t exist.

Maybe analysis was cool back in the 50's and 60's, when everyone smoked during sessions, and the analyst had a beard and a deep-voiced German accent and was a blank screen who only made comments about oedipal conflict. It's fun to watch in Woody Allen movies, but really, it's just a silly, archaic modality that thinks penis envy is the cause of everyone's problems, and now functions only as a narcissistic indulgence for the wealthy.

I once mentioned to a colleague I had just met that at certain hospitals, psychiatrists are not permitted to wear white coats because it makes the patients anxious. His response was, "That's just analytic bullshit!" I guess to most people, analysis qualifies as its own special category of bullshit.

Well, there is evidence that analysis works. Not only that it works, but that it works better than meds or CBT. I highly encourage readers to watch a 35 minute video on YouTube entitled, The Case for Psychoanalysis, Version 4, by John Thor Cornelius, a psychiatrist and psychoanalyst from California, who took on the challenge of convincing residents at UC Davis, who had been taught otherwise, that there is evidence for the usefulness of psychoanalysis. Obviously, he's made 3 earlier versions of the video, and he updates as new evidence becomes available. But I'm going to use highlights of the video (with his permission), and include other evidence, in this post.

Cornelius looked at effect size in meta-analyses of meds, CBT, and psychoanalytic psychotherapy, which he uses as a stand-in for analysis. The difference between analysis and analytic psychotherapy is something I'll get to in another post. Maybe. There's a lot of literature on it. For now, it'll have to be an adequate place-holder, and obviously, for my purposes, this is one of the limitations of his presentation.

Just quickly, effect size is the difference between treatment groups, expressed in standard deviations. Roughly speaking, a large effect size is 0.8, medium is 0.5, and small is 0.2. So, for example, if the effect size of A v. B is 0.8, then A did 0.8 of a standard deviation better than B, and this is considered a large effect.

 First, Cornelius looked at effect sizes at the ends of studies:

Erick H Turner, MD, Annette M Matthews, MD, Eftihia Linardatos, BS, Robert A Tell, LCSW, and Robert Rosenthal, PhD. Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy. NEJM 2008; 358:252-260 January 17, 2008.
Butler, AC, Chapman, JE, Forman EM, & Beck, AT. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26 (1), 17-31.
Abbass AA, Hancock JT, Henderson J, Kisely S, Short-term psychodynamic psychotherapies for common mental disorders. Cochrane Database Syst Rev. 2006;4:CD004687.
Maat S, De Jonghe F, Schoevers R, Dekker J. The effectiveness of long-term psychoanalytic therapy: a systematic review of empirical studies. Harv Rev Psychiatry. 2009;17(1):1-23.

You'll notice antidepressants aren't great, and CBT for chronic pain isn't either, but everything else does okay.

Then he looked at long-term follow-up, and this is what he found.

For antidepressants:

For Psychotherapy, there is evidence that its benefits endure and increase over time (Psychodynamic Psychotherapy Research: Evidence-Based Practice and Practice-Based Evidence (Current Clinical Psychiatry) [Kindle Edition]Raymond A. Levy (Editor), J. Stuart Ablon (Editor), Horst K├Ąchele (Editor)):

Leichsenring F, Rabung S. Effectiveness of long-term psychodynamic psychotherapy: a meta-analysis. J Am Med Assoc. 2008;300:1551-65.

MBT is Mentalization Based Treatment, an 18 month psychoanalytic partial hospitalization protocol for borderline personality disorder. 
Bateman A, Fonagy P. Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. Am J Psychiatry. 2009;165:556-9.

As for CBT, some of the results fall under Steps 2, 3, and 4 of the STAR-D trial, which had CBT arms. But here are some more results to consider:

40-50,000 patients per year for 5 years, $500 million dollars, and no effect of CBT. Those numbers big enough for you?

Next up, head to head comparison of psychoanalysis (PA), psychodynamic psychotherapy (PD), and CBT.

Comparison of cognitive-behaviour therapy with psychoanalytic and psychodynamic therapy for depressed patients – A three-year follow-up study (Z Psychosom Med Psychother 58/2012, 299–316), by Huber et al, is a prospective study of 100 patients diagnosed with unipolar depression and randomized into the three groups. I'm not including the studies this one follows-up on because this post is already too long.

"...mean duration of PA was 39 months (range 3–91) or 234 sessions (range 17–370), of PD was 34 months (range 3–108) or 88 sessions (range 12–313), and of CBT was 26 months (range 2–78) or 45 sessions (range 7–100); minimal values are due to the intent-to-treat approach."

PA was practiced at a frequency of 2-3 sessions per week, on the couch. PD was once a week, sitting up. And CBT was once a week.

There were 21 therapists, all past training, with mean duration of practice 15 years. 7 did CBT, and 14 did PA or PD, and there was no significant difference in respective training, expertise, and experience.

Raters were blind to treatment modality. They used a 3 year follow-up period to account for the naturally fluctuating course of depression. Treatment fidelity was also assessed.

"Outcome measures were the Beck Depression Inventory and Global Severity Index for measuring symptoms, the Inventory of Interpersonal Problems and the Social Support Questionnaire for measurement of social-interpersonal functioning, and the INTREX Introject Questionnaire for measuring personality structure."

I'm leaving out a lot of the methodological details, but I did want to give you the general sense that the study was conducted in a rigorous way. And these were the results:

"...at three-year follow-up, rate of remission from depressive symptoms was 83% in the PA group, 68% in the PD group, and 52% in the CBT group. When controlling age and gender, the odds of remission were significantly greater in the PA group as compared to the CBT group, with odds ratio (OR) = 4.79, 95% CI [1.29 to 17.74], and did not differ between the PD and CBT groups, with OR = 2.06, 95% CI [0.60 to 7.10]."

More generally, they found, "significant outcome differences between psychoanalytic therapy and cognitive-behaviour therapy in depressive and global psychiatric symptoms, partly social-inter- personal and personality structure at three-year follow-up. Psychodynamic therapy was superior to cognitive-behaviour therapy in the reduction of interpersonal problems."

In the discussion section, the authors were pretty good at describing the limitations of the study. They also addressed the question of a dose effect. We're talking 45 sessions of CBT vs. 88 sessions of PD vs. 234 sessions of PA. This is a fair question to ask, i.e., would 234 sessions of CBT have been as effective as the same 234 sessions of PA? However, the CBT lasted, on average, 26 months, while the PA lasted 39 months, only about a year longer than the CBT. At the rate of 1 session a week, or roughly 4 sessions a month, a CBT of 234 sessions would last for 58.5 months, or about 5 years, 2 years longer than the average psychoanalysis in the study lasted.

This was pretty farschlepped, but I hope you can see that there is some evidence that psychoanalysis is effective. Jeez, Dr. Lieberman, do your homework!

Tuesday, March 24, 2015

There and Back Again

The Hill: Hobbiton-across-the Water, by JRR Tolkien

I passed my MOC exam.  Friends and family have been teasing me about worrying that I wouldn't pass. I think it was a mild to moderate worry that I wouldn't pass, versus the severe unpleasantness of the consequences of not passing.

I found out 5 weeks to the day after taking the exam. The ABPN emailed me and told me I could check my score on ABPN Folios, although that would just indicate pass or fail.

They also sent information via mail, including my exact score, a breakdown of my sub-scores, a breakdown of the exam by section, and other information, which I'll get to later on.

One piece of information for people planning to take the exam soon, that I don't think I knew before the exam, or maybe I did, is that the passing standard for 2015 is 66%. I got an 85%. I wasn't planning to share the details of my scores, and it makes me a little uncomfortable to do so, but on consideration, I decided that it might be helpful to see how I did, compared with how I prepared and how I thought I did-see my posts, Done, Percentages, and The Evil Emperor MOC.

So here's the chart I came up with:

I had felt there were proportionally fewer Mood d/o questions. This seems to be a distortion on my part, although it's possible the Mood d/o questions were closer to 11%, and Psychotic, Substance and Anxiety were all closer to 15%. But it's good to know that the bulk of what psychiatrists see was represented in the largest proportion.

I had mentioned that I thought there were a lot of Personality d/o questions. I guess I was right about that. I was also right about the fact that I wasn't as well-prepared for these questions, reflected in my score of 77%.

I had felt well-prepared for the substance and neurocognitive d/o questions ( I don't think I mentioned that latter, in my previous post, but I talked to colleagues about it), and this is also reflected in my scores.

I don't take the lower "% of Exam" area scores very seriously. Like, maybe there were two questions on Dissociative d/o's and I got 1 wrong.

So it looks like I was reasonably well-prepared for the exam. My only advice to people about to take it would be not to bother with CYP-450 stuff, and focus more on personality d/os.

Now for the "back again" part.

The score report came with other information about MOC. Specifically, I'm now automatically enrolled in C-MOC, or Continuous Maintenance of Certification. My new board certificate no longer has an expiration date. I was pleased when I read that part. I thought, well, maybe I won't maintain my MOC, but I'll at least feel like I'm maintaining it.

Most of you reading already know this, but just in case, C-MOC consists of 4 parts. 1. Maintain professional standing. 2. 90 CME category 1 credits, including 24 Self Assessment (SA) credits, every three years. 3. Exam every 10 years. 4. Performance In Practice (PIP) once every three years.

Plus, you have to attest to completed MOC activities annually, and there's also an annual fee of $175, and here I'm quoting:

The annual fee covers maintenance of Board certification status, use of personalized Physician Folios account with customized MOC tracker, development and administrative costs of MOC examinations, including credit towards an MOC examination in a 10 year period.

How much does it cost them for me to "maintain" my board certification status-in other words, do nothing? And I already have a Folios account with a hard-to-use MOC tracker. As to development of MOC exams, I feel like, if I'm paying for it, I should be able to contribute to the decisions about what's covered on the exam. And if the $1750 total is only a "credit towards" another exam, what extra charges am I gonna get?

To me, it sounds like the ABPN is becoming aware that not only are they not the only game in town, but they better make sure to get you hooked in right away, because 10 years down the line, they're likely to lose you.

I thought somehow, by magic, having taken and passed this last exam, I would be spared having to give it a thought for another 10 years. I figured I'd rack up my 300 CME credits, ignore the SA credits, because some time in the next 10 years, the SA thing will be exposed for the racket it is, and be removed. Same for the PIP stuff, which is already circling the drain. And then 10 years from now, the dust will have settled, and I can decide whether it's worthwhile for me to take another exam, or if the ABPN and the ABMS have become a total joke, and my other board certifications are all I need. That's part of the fantasy, that in 10 years, I'll have multiple, non-ABPN, board certifications.

It was not to be. Some time in the next year, I have to decide whether I want to pony up the $175 to continue this trajectory, or take a stand opposing the shameful scam of MOC.

Did you know that in the 2nd Harry Potter movie, Harry Potter and the Chamber of Secrets, there is a large painting of Gandalf just over the door in Dumbledore's office. So in the words of that other great wizard:

"Dark and difficult times lie ahead. Soon, we must all face the choice between what is right, and what is easy."

Leaving the Shire, Ted Nasmith

Sunday, March 22, 2015

Limits of Technology

The other day, I went to see a new physiatrist for my chronic back problems. She came highly recommended by my former physiatrist, who retired. I found her (the new one) to be lovely and helpful, as was her staff. No problem with the people.

The technology was concerning, though.

Some things they got right. The doctor typed on a computer while we talked, but she had the monitor and keyboard raised and next to the examining table, so that she wasn't constantly looking down or away. I didn't find that off-putting at all, surprisigly. And when I first registered, the receptionist asked for my email address. I declined, because I don't want to be spammed by the hospital she's affiliated with. The receptionist told me that it's for something called, "My Charts", where I can look up my results and summaries of my visits, and where I can easily communicate with my doctor. I still declined.

Later, the physiatrist encouraged me to sign up for My Charts. She didn't know I had refused. She obviously uses it regularly, so I decided to do it, and I sheepishly told the receptionist that the doctor had convinced me, and gave her my email.

What I didn't like about the technological aspect was the initial forms. Well, "forms". I was handed a tablet, and asked to fill out privacy and insurance forms that way.

Problem 1: The thing is a fomite. There are typical hospital-type signs in the office about properly wiping down all shared equipment with cleaning products, but you can't really do that with a tablet, and dude, this thing was not clean.

Problem 2: The user interface was crappy, but that's no surprise.

Problem 3: The software was less sophisticated than paper forms. When you're handed a paper HIPAA form, you can decline to sign it, and the doctor simply has to document that she made a good faith effort to give you the forms. Your lack of signature does not in any way prevent the sharing of information that HIPAA allows. In other words, your information can get tossed around publicly, whether you agree to it or not. If you don't believe me, see my post, What, Exactly, Is HIPAA?

The electronic version had no option for not signing. With paper forms, I generally refuse, because even if I have no say in what happens to my information, I don't have to jump on board that bandwagon by obsequiously signing. But I couldn't finish the electronic form without signing.

There were 4 different documents I had to sign. One said that if I didn't agree to the terms, I wouldn't be treated. At least I think that's what it said. The lack of clarity is another problem.

A second form was a standard, "I agree to share this info with my insurance," which I know I have to sign if I want coverage. And I was pleased that this doctor, who came so highly recommended, happened to be in my network. This is part of the upside of technology, which, if done well, can make it possible to manage a high volume practice that takes insurance but still makes money, and also treats patients well. And this practice, unlike my own, is high volume.

Another form gave me two final options. I could either agree to share all information with other providers, or I could refuse to share any information with other providers, including in an emergency. It specified that part. Then there was a line below the options that said if I didn't choose one or the other, it would be assumed that I wanted to share no information, except in an emergency. I thought, "Oh, good. I won't choose." Naturally, the software wouldn't let me do that. So I refused the sharing of any information, on the assumption that in an actual emergency, any intelligent doctor would just go ahead and get the necessary history.

There was one other form, and I can't remember what it did.

Like I said, paper forms would have made more sense. It was galling that there was a big sign in the office touting the use of these tablet forms, and how they would allow for better patient care.

I'm not comfortable having my health information readily available to pretty much everyone. In an article in yesterday's NY Times, Why Health Care Tech Is Still So Bad, Robert Wachter describes a lot of what I just did, but with the hope that today's tech is really version 1.0, and that it'll get better. He points out the flight industry wouldn't dream of using new software until it was tested extensively by pilots in simulation. Not so in health care. Go figure. And Apple interface, especially with iPhones and iPads, is a pleasure in large part because Steve Jobs was a tyrant who wouldn't market a product until it worked the way he wanted it to. Not so in health care. Maybe we need a Steve Jobs.

But the line that struck me from the Wachter piece was, "Big-data techniques will guide the treatment of individual patients, as well as the best ways to organize our systems of care. (Of course, we need to keep such data out of the hands of hackers, a problem that we have clearly not yet licked.)"

Personally, I'm far less concerned about hackers getting my health information than about insurance companies and the government getting my health information. Who else would hackers sell it to?

Wednesday, March 18, 2015


Guess what!

Something new is happening in New York State. Disclosure requirements for providers. Here's the scoop:

Summary of New Disclosure Requirements for Providers

New York State Public Health Law Section 24

Effective 3/31/15

Health care Professionals or Group Practice

Information to be provided in writing or on the health care professional’s website prior to the provision of non-emergency services:
·         The health care plans with which the provider participates [PHL § 24(1)].
·         The hospitals with which the health care professional is affiliated[PHL § 24(1)].

Verbal information to be provided at the time an appointment is scheduled:
·         The health care plans with which provider participates [PHL § 24(1)].
·         The hospitals with which the health care professional is affiliated[PHL § 24(1)].

Information to be provided when the Health Care Professional does not participate in the network of a patient's or prospective patient's health care plan:
·         Prior to the provision of non-emergency services, inform the patient or prospective patient that the amount or estimated amount the patient will be billed for health care services is available upon request [PHL § 24(2)(a)].
·         Upon receipt of a patient or prospective patient’s request, the amount or the estimated amount (in writing) the patient will be billed for health care services, absent unforeseen medical circumstances that may arise when the health care services are provided [PHL § 24(2)(b)].

There's more, like you need to be very specific when referring a patient to another provider, and there's stuff for hospitals, too.

This is the Emergency Medical Services and Surprise Bill, enacted because patients were seeing new doctors without realizing these doctors weren't in-network, and then getting stuck with an unexpected bill. A lot of times this happened because insurance companies have out-of-date in-network provider lists, so patients would go to someone on the list, thinking they'd be covered. Here's a link to a summary of the problem, published in 2012, An Unwelcome Surprise.

And here's an article from about a year ago, published in Families USA, New York’s New “Surprise Bill” Law Rolls out New Health Insurance Protections for Consumers , that summarizes the law. Basically:

Insurers have to keep their in-network lists up to date.

Providers need to inform patients of their network and hospital affiliations.

Providers need to tell patients they have the right to know what the bill will be like, and if the patient asks, the approximate amount, barring anything unforeseen.

You have to tell your patient how to find out how much their network will cover for any doctors you refer them to.

And analogous stuff for hospitals.

It also allows patients to get out of network care, at the expense of the insurance company, if there is no comparable inpatient care. And when there are disputes about the care that's available-like that would ever happen-these need to go through an independent review process.

And another part of the deal is that insurers need to guarantee adequate care be available in-network:

In New York, all health plans must now meet network adequacy rules to reduce the use of more expensive out-of-network medical services 

Notice that the purpose is to cut costs, not provide good care.

Notice, also, that the problem is precipitated by lack of out-of-network coverage, out of date network provider lists, and incomprehensible reimbursement rules.

So the obvious solution is to have the evil out-of-network doctors take over the responsibility of informing the patient that they're out-of-network, and figuring out how the patient can figure out what they'll be reimbursed.

I can understand how this law is helpful to patients, especially in settings like large group practices, where they get plied with impersonal bills. It has no place in a private psychiatric practice like mine. I don't have a website. I don't give new patients a clipboard with HIPAA forms and PHQ-9s and office policies in the waiting room. And I sure as shootin' won't have a bunch of legal rubes telling me how to talk to a new patient. As far as I'm concerned, therapy begins from the moment the patient picks up the phone to make an appointment. Interactions around payment are part of the treatment process, and whoever drafted the law doesn't have the training to dictate how therapy should be practiced.

Oy, so many battles. Remove Part IV of MOC, get a new certifying board, postpone e-prescribing for a year, get some out of network plans on the NY exchange. I'm exhausted. I was almost too exhausted to write this post, in fact, but then I had an idea.

What if I were to comply with this law the way contracts include unpleasant clauses, and drug ads disclose potential adverse effects? That's right, small print, and rapid, barely comprehensible speech, like on The Simpsons, in the commercial for Viagrogaine for baldness and impotence, at the end, the announcer says, "Possible-side-effects-include-loss-of-scalp-and-penis."

I participate in Federal United Care-Universal (FUC-U) plans. $17,000 per session. Rates are not guaranteed.

Monday, March 16, 2015

An MOC Step?

Email today from the APA:

Dear Colleague:
The APA Board of Trustees is aware of members’ significant concerns over the “Part IV: Improvement in Medical Practice” portion of the American Board of Psychiatry and Neurology (ABPN) Maintenance of Certification (MOC) Program. Therefore, yesterday, the APA Board voted unanimously in support of the following motion:
  • The American Psychiatric Association (APA) Board of Trustees, acting on the recommendation of the Assembly Executive Committee, and representing over 36,000 psychiatrists, supports the elimination of Part IV of Maintenance of Certification (MOC).
  • Therefore, the Board of Trustees recommends to the American Board of Psychiatry and Neurology (ABPN) that they lobby and advocate the American Board of Medical Specialties (ABMS) to eliminate Part IV of the MOC,
  • that the APA reaffirm its commitment to lifelong learning and quality improvement and support for the highest scientific and ethical standards of medical practice, and
  • that the APA will establish a joint Board and Assembly Work Group with the charge to evaluate the broad issue of maintenance of certification for psychiatry and its relationship to maintenance of state licensure and other accrediting bodies. The goal of the work group is to return timely reports to the Board and Assembly including recommendations, if appropriate, for any positions the APA should take regarding any and all parts of MOC.
APA CEO and Medical Director Saul Levin, MD, MPA, and I have sent a letter to the ABPN, which is clear about the confusing and cumbersome nature of the program and the substantial concern which our membership and the Board of Trustees has regarding the evidence base of Part IV of MOC. At the same time, the Board further reaffirmed the APA’s “commitment to lifelong learning and quality improvement and support for the highest scientific and ethical standards of medical practice.” I look forward to being able to share the Board-Assembly Work Group’s findings in the near future.
We highly value our collaborative relationship with the ABPN and will work with them, other groups and, of course, our members to resolve the widespread concern about these issues.

Summergrad, MD
Paul Summergrad, MD
American Psychiatric Association

To remind people, Step IV consists of the Performance In Practice (PIP) modules, the 5 peer reviews, and the 5 patient reviews, which I wrote and complained about in one of my earliest posts, Alphabet Soup, back in November of 2012. Currently, we are no longer required to do both the peer and patient reviews (and I consider these last to be a boundary violation), but rather, one or the other, or a couple of other possibilities which I was going to cut and paste from the ABPN page, but for some reason the chart won't load on my computer. I think two of them are a 360 degree review and 5 resident reviews.

So now, the APA has FINALLY jumped on the bandwagon, when they see that there are other certifying boards (like the National Board of Physicians and Surgeons, see my post, Another Board) out there that don't require crazy PIP modules that have no evidence to support their utility. The PIP modules are a money-maker for the APA, or at least they have been, so I assume the motivation for getting rid of them as a requirement comes from the fact that the APA is losing membership and money, and may lose more if its members recall that the APA did absolutely nothing to prevent the institution of these requirements, to begin with. Only now are they establishing a Board and Assembly Work Group.

I guess I'll take what I can get from the APA, and maybe this is better than nothing. But they've done poorly by their constituency with regard to MOC in the past, and I don't see any reason to assume they'll do any better in the future, unless supporting their constituency happens to coincide with their own interests, whoever "they" are.

Friday, March 13, 2015

ICD-10 List

Am I missing something about ICD-10? There's a whole lot of fuss about preparing for the transition and testing of systems to see if they comply with the transition. Don't you just need to use a different code? I guess it's more complicated in something like orthopedic surgery, where there's a lot more specificity you can get with ICD-10. And if you use an EMR or some kind of billing system, it needs to generate the new codes. See how it's so much easier not to use an EMR?

Here's a link to ICD-10 Basics. It includes a "Build Your Action Plan" link. I tried it out. It asked for my specialty (Other), how many physicians in my practice (1-2), what technology I used (EHR, which includes ERx), What type of insurance I take (none), and what stage of ICD-10 readiness I'm at (planning).

It gave me this:

Out of curiosity, I tried it again with Orthopedics, 3-6 physicians, EMR/Billing System, Commercial insurance and medicare, and planning stage. It gave me the exact same action plan.

Well, anyway, in preparation for the switch to the ICD-10 coding system this October, or maybe the following one, or the one after that, or some time in the next decade, I decided to smooth the transition for myself by making a list of my most frequently used ICD-9 codes, and converting them to ICD-10 codes via the ICD-9 Diagnosis Converter, which I mentioned in a previous post.

A couple of brief notes:

Only HIPAA covered entities are required to comply with mandatory ICD-10 coding. I'm not a HIPAA covered entity, but I'm going to do it anyway, since it will probably confuse insurance companies if I don't. Or maybe that won't matter because no one will have out of network mental health insurance.

There are two coding systems-ICD-10-CM, and ICD-10-PCS. The difference is that the PCS system is only for inpatient coding.

I currently don't use DSM codes, just ICD-9 ones, so you may need to adjust accordingly. I do this mainly as a form of protest, but also because the ICD system allows for more flexibility in terms of the types of patients I treat. For example, ICD-9 300.4 is Dysthymia, which is the same in DSM. But in ICD-9, Dysthymia includes things like "Depression with Anxiety" and "Neurotic Depressive State"-all billable.

The other point I want to make is that if you have access to DSM-5, you'll notice it includes ICD-10 codes. But I still thought that, at least for myself, it would be helpful to have a simple list of my most commonly used diagnoses, But I also thought I'd add a few more codes that I don't see very frequently, but might be helpful to others.

Finally, it's interesting to note that there's not a direct 1:1 correspondence between DSM-5 diagnoses and ICD-10 diagnoses, and a lot of times, you have to make your best guess. I"m not sure where that leaves DSM-5 in terms of how definitive it believes its diagnoses are.

So, here goes.

In ICD-10, Mental, Developmental, and Neurodevelopmental disorders are coded with an "F" as a prefix, from F01-F99. This is in contrast with Diseases of the Nervous System, which have the prefix, "G". And again, I wonder what implications this distinction has more generally.

There are 10 different sections, from "Mental disorders due to known physiological conditions" to 'Behavioral and emotional disorders with onset usually occurring in childhood and adolescence", plus F99, the meta-vague "Unspecified Mental Disorder".

I'll start with Depressive d/o's:

Note the difference from ICD-9, where the equivalent severity specifiers run from 1 to 4, rather than 0 to 3.

Also note that ICD Dysthymia is different from DSM Dysthymia. It includes the DSM version of Dysthymia, but it extends it:

Clinical Information
  • A term used for any state of depression that is not psychotic
  • Chronic affective disorder characterized by either relatively mild depressive symptoms or marked loss of pleasure in usual activities
  • Chronically depressed mood that occurs for most of the day more days than not for at least 2 years. The required minimum duration in children to make this diagnosis is 1 year. During periods of depressed mood, at least 2 of the following additional symptoms are present: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self esteem, poor concentration or difficulty making decisions, and feelings of hopelessness. (dsm-iv)
  • Depression precipitated by events in a person's life
Applies To
  • Anxiety depression
  • Depression with anxiety
  • Depressive reaction
  • Neurotic depressive state
  • Reactive depression
Disease Synonyms
  • Anxiety associated w depression
  • Anxiety depression
  • Anxiety with depression
  • Depression, reactive
  • Dysthymia
  • Mixed anxiety and depressive disorder
  • Reactive depression
  • Reactive depression (situational)

For the purposes of my practice, this is a really useful diagnostic category, because there's a lot of leeway for depressive symptoms.

Bipolar d/o's:

ICD-10 has a separate heading for Manic Episodes and bipolar D/O.

This is a little fiddly, but Bipolar D/O excludes
* bipolar disorder, single manic episode
* major depressive disorder, single episode
* major depressive disorder, recurrent
* cyclothymia

But it includes
* manic-depressive illness
* manic-depressive psychosis
* manic-depressive reaction

Manic Episode without Psychotic sx is F30.1x,
where x = 0 for unspecifed, 1 for mild, two for moderate, and 3 for moderate without psychotic sx.

This differs from the severity specifiers listed above for MDD.

However, Manic Episode, severe, with psychotic sx has its own code, F30.2

Furthermore, Cyclothymia has a completely separate code, F34.0, and it includes:

* Affective personality disorder
* Cycloid personality
* Cyclothymia, and
* Cyclothymic personality

And more:

Note: Other specified PDD is Asperger's in ICD-10.

And finally, since there are so many different types of substances of abuse, I'm only including Alcohol:

In general, I don't think it matters much what number you put down, except for billing purposes. But it's clear that the ICD system thinks about mental disorders somewhat differently than the DSM does.

Here's a little comic relief to end with. There are some ICD-9  codes that have the same letters and numbers (sometimes with changes in decimal places) as some ICD-10  codes, but mean completely different things. For example,

ICD-9  E802.0 = Railway accident involving derailment without antecedent collision injuring railway employee

ICD-10  E80.20 = Unspecified Porphyria

And finally, finally, if you check the top of the blog, you'll see I've added an additional page, right next to, "Disclaimers," entitled, "ICD-9 to ICD-10 Transition," which is the entire table in one place, albeit a little wonkily, for future reference.

Wednesday, March 11, 2015

Out Of Network Benefits in NY

As I've previously mentioned, I may need a new job in the not-too-distant future, because as of right now, there is no out of network mental health coverage on the exchanges in NY State. I've already had to lower fees for several patients, and see some of them less frequently, because they no longer have the insurance coverage they had last year. This is going to create a staggering problem in NY. There will be an even more stratified system for outpatient psychiatric care, particularly therapy, because shrinks will either have to restrict their practices to people who can pay them out of pocket, or in many cases, leave private practice because they can't afford to run one anymore. And I know most people don't have much sympathy for doctors who don't make as much money as they'd like, but it costs money to run a practice, and doctors, like other Americans, are inalienably entitled to the life, liberty, and the pursuit of property. So have some compassion for patients who need mental health care, and for the people who care for them, and sign the petition to keep out of network coverage on the exchanges.

Saturday, March 7, 2015


I learn a lot on the subway. I spend quite a bit of time commuting. Some days I'm too tired to do anything but play Temple Run2. But I also read recreationally and professionally. And when my eyes aren't otherwise occupied, I look at ads. There's the famous, and recently less present, Dr. Zizmor, the world-renowned dermatologist:

There are all the ads for law firms with track records of successful malpractice suits.

There's the MTA's Poetry in Motion campaign:

Notice that Dr. Zizmor's ad is rectangular, and the Elephant poem is more square. The rectangular ads run across the tops of subway cars, and the square ads run below, to the sides of doors. Often, one company will take up multiple ad spaces in a single car, with different versions along the top and on the side.

There's a company, Manhattan Mini-Storage, that has pretty amusing ads all over the city, including in the subways, that encourage you to clear out your crowded NYC apartment by using their storage, like this one:


A couple weeks ago, I saw a rectangle ad above a square ad, that I assumed were part of the same campaign, since they had the same tag line, "Dream Big", and roughly the same font:  Sorry for the crummy iPhone photo:

Turns out, the bottom ad is for NYU's school of continuing education, and the top ad is for breast augmentation.

But today, I saw an ad for Talkspace:

Talkspace is unlimited messaging therapy for $25/week, billed monthly. (There are other rate plans, as well.)

"...you can now message your therapist every day..., writing as many times as you want..."

There's also live video therapy, $29 for 30 minutes, but this needs to be scheduled ahead of time. And there's couples therapy.

Here's their video:

All kinds of questions, right?

Like, who are these therapists?

There doesn't seem to be anyone I could find with an MD, PhD, or Psy-D. All Masters level. Talkspace says they check the credentials of all their therapists, but the therapists don't work for them, and Talkspace isn't responsible for what they do. They just facilitate the connection.

From their FAQs:

What is Talkspace about?

Talkspace is making therapy available and affordable for all...

We created Talkspace because we strongly believe that in this day and age, everyone should have real-time, simple, and affordable access to professional advice whenever and wherever we need it. get access to leading therapists who can help you overcome your day-to-day challenges. 

Talkspace  is your safe and secure place where with a licensed therapist you can start your journey to fulfillment, empowerment, and happiness. You can share what's on your mind, chat privately with a therapist on your computer or mobile device.

Is online therapy really effective?

Absolutely. If done correctly, by qualified individuals and in the right environment.

Over the last decade numerous prominent research studies have proven the effective potential of online therapeutic conversation. We listed a few on our Talkspace blog research page.

I checked out the list. A lot of the references are newspaper articles, which I'm just ignoring. There are a couple of references to papers having to do with online therapy. These tend to be specific to a condition being treated, or to a specific modality of therapy with predetermined time constraints. They didn't seem to list anything that directly supported the type of "online therapy" they do-unlimited access, text-based.

Is Talkspace a substitute for actual therapy?

No. Talkspace does not aim to create an alternative or competitor to offline therapy.

Rather, we create a doorway for dealing with real life issues that may be an element in our lives, but may not necessarily require full clinical psychiatric process.

Furthermore, therapists are instructed to identify situations where clinical therapy is needed and divert participants towards the most appropriate solution.

So, Talkspace makes "therapy available and affordable for all", but it's not a substitute for actual therapy.

What about my privacy?

At Talkspace your privacy and safety are always the first consideration. We went to great lengths to assure you and your data are always kept safe and confidential

Your safety is our #1 priority. You have the option to remain anonymous. 
Our technology is fully HIPAA compliant. 

I was a bit confused by this part. The site has 141 free therapist-led forums. This is from one called, "How to deal with depression or anxiety":

I guess there's some privacy, since the therapist offers a private chat, but it seems like a lot of information is right out there for anyone to see.

Another comment from the same forum has a lot more information than I'm comfortable with. I suppose if the person posting doesn't mind, it's okay:

I'm also a bit put off by the response:

The therapist seems not to have noticed that the father is dying, not dead.

Call me skeptical, but I have a hard time believing that text therapy can be helpful. Tele-therapy or Skype-therapy is limited enough. Texting makes it completely impersonal.

In terms of therapeutic alliance, it's not even clear to me if you always get the same therapist. I don't see how you could, since they're supposed to be available 24/7.

Also, the responses on the forums are so simplistic, it's hard to imagine anyone finding them more helpful than speaking to a friendly neighbor:

"...it sounds like you are the type of person who likes to please and make others happy but you are not taking care of your own needs."

"...it's about building up your self-esteem and confidence so that you don't have that fear of people liking you or you feeling the need to make others like you."

But mostly, I'm concerned because the whole 24/7 access setup is so anti-therapeutic. The frame is always important to therapy. It creates safety and containment. Scheduling, boundaries, recognizing the limitations in the therapeutic relationship.

What happened to using therapy to learn how not to need therapy? We want patients to carry their therapists around in their hearts and minds, not in their pockets.

And Talkspace completely misses an important aspect of limited access, namely, that the patient learns that other than in a true emergency, he or she can tolerate some anxiety and frustration, and wait until the next session to discuss what seemed like very pressing feelings.

Talkspace will just push people further away from the ability to tolerate delayed gratification.

Addendum: I published this post just a few hours ago, but I just saw the Circa Now column in the NYTimes, and I had to add a link:

Memo to Therapists: It's Not Me, It's You

The author, Henry Alford, writes about wanting to break up with his therapist "on day 2 of our relationship", which takes place on Talkspace. The article is really about awkward and difficult interactions with ones therapist, and how these can be handled well, or poorly. In the cases in the article, mostly poorly.  And it's interesting that the patients quoted in the article have trouble bringing up uncomfortable feelings and thoughts with their therapists, like, "Is it okay to ask my therapist about herself 2 years into the therapy?", or, "Can I mention the fact that my therapist just farted?" without the realization that these are the kinds of things that need to be discussed in therapy, precisely because they're uncomfortable, and politeness has nothing to do with it. And I'm inclined to blame their therapists for not making that clear, or creating an environment that makes it possible to say difficult things.

The article is not about Talkspace, per se, but the timing was so uncanny, I had to include it. And the author does seem to think the activity he's participating in on Talkspace is therapy.

Sunday, March 1, 2015

Father Disappoints Again

Here's a link to an article from a couple days ago in the NYTimes, about Vyvanse for Binge Eating Disorder (BED).

The article claims that Shire promoted awareness of the "relatively rare" Binge Eating Disorder, including giving $100K to the Binge Eating Disorder Association last year, before finally marketing Vyvanse to treat the disorder.

It also claims the FDA should have been more cautious about approving a drug with a high potential for abuse.

In addition, it points to the fact that, "Shire appeared to be following a familiar drug industry playbook by promoting awareness of a disorder, in this case binge eating, before more directly marketing its treatment. A company website, BingeEatingDisorder.com, makes no mention of Vyvanse but provides detailed information about how to talk about the disorder with a doctor, including a printable symptom checklist and sample opening lines to start the conversation. The site also tells patients “don’t give up” if a doctor initially resists."

Here are the recommendations for speaking to ones doctor about BED:

So here are some of my thoughts:

Shire is sleazy. It already paid $56.5 million to settle federal charges for improperly promoting drugs. And $56.5 million is nothing to a drug company.

The NYTimes is sensationalist, and conveniently points a finger at the FDA. Seriously, Vyvanse was already FDA approved for ADHD, so it didn't suddenly become unsafe, or more prone to abuse than it already was.

The first labeling change was on January 30th. It looks like this:

The label from November of 2014 only includes an indication for ADHD. Also note, Vyvanse is only approved for Moderate to Severe BED, and NOT indicated for weight loss. There's also a warning about abuse:

It bothers me that the Times is intent on pointing to the FDA. The FDA has a job to do, and sometimes it screws up, but I think we often attribute almost magical powers to it. Stepping away from the fact that the F stands for "food", and that it's a pretty big responsibility to oversee all the drugs AND foodstuffs in the country, so of course there are going to be mistakes, and stepping away from the fact that any large organization is going to have some graft, the FDA's job is just its job. Companies that want a drug approved have to submit applications, run studies, prove safety, and prove efficacy against placebo, but that's it. Sure, there is a fast track program that was legislated into effect by the ACT UP movement, and it's sometimes abused, but it exists for a good reason.

I'm not trying to defend the FDA. I just don't think it needs to be defended. It's not its job to determine the morality of a drug with potential for abuse, and it's not its job to determine the validity of a diagnosis. And it's not its job to make decisions for physicians about their prescribing practices, or for patients about how and whether they abuse their medications.

We never really lose the wish for an omnipotent parent who will have the wisdom and ability to protect us from harm, both from without and within. And we continue to be disappointed when we don't find that parent where we expect to.