One of my favorite lines from the Harry Potter books is the neon sign in the window of Fred and George's joke shop:
Why are you worried about You Know Who?
You should be worried about You-No-Poo!
The constipation sensation that's sweeping the nation.
Take a break from worrying about DSM and SAFE and I-STOP and E/M coding.
Here, read this amazing article, and start worrying about EHRs.
Monday, June 17, 2013
Thursday, June 13, 2013
What, Exactly, Is HIPAA?
The term, "HIPAA" gets thrown around in relation to patient confidentiality, so I thought it might be useful to clarify exactly what HIPAA is.
My understanding of a HIPAA-covered entity, at least for private practice, has been that you're a HIPAA Covered Entity if you bill electronically. End of story. Here's a government chart to corroborate my opinion.
Specifically:
I don't bill electronically, therefore, I am not a HIPAA Covered Entity.
Now, if you do bill electronically, or work with a billing service, then you are a HIPAA Covered Entity. But again, you are restricted in terms of the billing, not other areas.
This is a link to a useful fact sheet from HHS. Some key points:
Health Insurance Portability and Accountability Act (HIPAA) does not require patients to sign consent forms before doctors, hospitals, or ambulances can share information for treatment purposes.
So you can share patient information with other health care providers without the patient's consent.
I think it's still a nice idea to get consent, anyway, but you are not in violation of HIPAA if you don't have it.
HIPAA does not cut off all communications between providers and the families and friends of patients
You can share needed information with family, friends, or caregivers, as long as the patient doesn't object. And if the patient is unable to indicate a preference, you can do what you think is best.
So let's get something straight once and for all. HIPAA is not a catchall term that describes all legal issues surrounding patient privacy and confidentiality. It's about billing electronically.
The next time you hear someone try to reassure you by saying he or she is restricted from revealing patient information because of HIPAA, Uh-Uh.
If you're a HIPAA covered-entity, you need to give your patients forms indicating how their information may be used. And you need to make a good faith effort to get them to sign a form acknowledging receipt of these forms. What you don't need to do is get the patient to consent to the release of information. And in fact, these forms are more about the ways in which the patient's information lacks privacy.
The sample Patient Privacy Notice from NYU Langone includes the following ways a patient's health information may be used, without consent:
Treatment
Payment
Business Operations
Appointment Reminders
Fundraising
Education
Business Associates
Electronic Communications
Research
Public Need
Doesn't sound all that private, to me.
There are non-HIPAA laws regarding patient privacy, doctor-patient privilege, and confidentiality, and these vary by state. I'll go into more detail in a future post.
But for now, PLEASE read Shrink Rap's post on KevinMD for a description of what can happen to privacy under the auspices of "HIPAA".
So let's get something straight once and for all. HIPAA is not a catchall term that describes all legal issues surrounding patient privacy and confidentiality. It's about billing electronically.
The next time you hear someone try to reassure you by saying he or she is restricted from revealing patient information because of HIPAA, Uh-Uh.
If you're a HIPAA covered-entity, you need to give your patients forms indicating how their information may be used. And you need to make a good faith effort to get them to sign a form acknowledging receipt of these forms. What you don't need to do is get the patient to consent to the release of information. And in fact, these forms are more about the ways in which the patient's information lacks privacy.
The sample Patient Privacy Notice from NYU Langone includes the following ways a patient's health information may be used, without consent:
Treatment
Payment
Business Operations
Appointment Reminders
Fundraising
Education
Business Associates
Electronic Communications
Research
Public Need
Doesn't sound all that private, to me.
There are non-HIPAA laws regarding patient privacy, doctor-patient privilege, and confidentiality, and these vary by state. I'll go into more detail in a future post.
But for now, PLEASE read Shrink Rap's post on KevinMD for a description of what can happen to privacy under the auspices of "HIPAA".
Wednesday, June 12, 2013
DSM-5 in Action
Last week, I saw a new patient who was referred to me by her therapist for evaluation for med management, specifically, for depression.
The therapist wasn't certain the patient needed meds. And the patient wasn't sure she needed, or wanted meds.
She was suffering-that was the only certain thing.
I'm a decent psychopharmacologist, despite the fact that I mostly do therapy and analysis. The reason I'm good with meds is not because I'm an expert on the Cytochrome p450 system, or I'm the first shrink on the block to prescribe a brand new med. I believe it's because I listen to my patients, so important feelings/experiences/symptoms don't get overlooked, or boxed into neat little 15-minute med check categories that don't really fit.
So I listened to this patient, and while I was listening, I started thinking about everything I've learned regarding DSM-5. Like, maybe Major Depression, as defined by the DSM, doesn't really exist. (Note: I am NOT saying I don't believe depression exists. I'm just referring to the DSM definition of depression). And even if it does exist in DSM form, if I run through the checklist, and the patient meets five of the nine criteria, does that imply that she'll benefit from medication? And if she doesn't meet 5/9, does that mean she won't?
And what about the meds? What exactly am I treating? And how? A world-outlook? A traumatic childhood loss? If I can't be sure there's a disease process going on, and I can't be sure which aspect of the disease, if such it is, I'm treating, and no one even knows how the meds work, then why would I medicate?
I thought about how easy it would be to say to her, "You meet criteria for MDD, here's a pill, take it and you'll feel better." But I just couldn't bring myself to do that. I didn't believe it would help.
This is not the first patient I've sent home prescription-less. But it's the first time I've thought about it this way. In the past, I might've said to myself, the patient doesn't meet criteria, and therefore doesn't have the disorder in question, and consequently won't benefit from medication for this condition.
But now I'm reminded of the joke about the philosophy exam question, asking students to describe the physical characteristics of the chair at the front of the room. One student's response: What chair?
What disorder?
I came up with the following analogy: Suppose I decide that people who have more than 5 bad hair days per month carry a diagnosis of BHDD (Bad Hair Day Disorder). Am I describing an entity? Yes, people who have too many bad hair days. Does that make it a disorder, or disease?
I'm not sure the analogy is valid. At least some of the DSM diagnoses have a basis in clinical experience.
The truth is, and I realized this while I was writing, that I do find the DSM criteria for MDD useful, as a line of questioning.
This patient did not fit into any nice little DSM category. And I didn't try to make her fit. My thinking was, let's explore what she's been experiencing, using DSM criteria as a starting point. And that was useful.
I haven't purchased a copy of DSM-5. I don't want to. And I resent that, despite all the protests to the contrary, it remains the "bible" of psychiatry, and decisions are made based on its contents-reimbursement decisions, legal decisions.
But I do wish it could be what it professes to be: a guideline. Then it could sit on my book shelf with all the other books I use as references and guidelines, not with pride of place, and not with shame, either.
The therapist wasn't certain the patient needed meds. And the patient wasn't sure she needed, or wanted meds.
She was suffering-that was the only certain thing.
I'm a decent psychopharmacologist, despite the fact that I mostly do therapy and analysis. The reason I'm good with meds is not because I'm an expert on the Cytochrome p450 system, or I'm the first shrink on the block to prescribe a brand new med. I believe it's because I listen to my patients, so important feelings/experiences/symptoms don't get overlooked, or boxed into neat little 15-minute med check categories that don't really fit.
So I listened to this patient, and while I was listening, I started thinking about everything I've learned regarding DSM-5. Like, maybe Major Depression, as defined by the DSM, doesn't really exist. (Note: I am NOT saying I don't believe depression exists. I'm just referring to the DSM definition of depression). And even if it does exist in DSM form, if I run through the checklist, and the patient meets five of the nine criteria, does that imply that she'll benefit from medication? And if she doesn't meet 5/9, does that mean she won't?
And what about the meds? What exactly am I treating? And how? A world-outlook? A traumatic childhood loss? If I can't be sure there's a disease process going on, and I can't be sure which aspect of the disease, if such it is, I'm treating, and no one even knows how the meds work, then why would I medicate?
I thought about how easy it would be to say to her, "You meet criteria for MDD, here's a pill, take it and you'll feel better." But I just couldn't bring myself to do that. I didn't believe it would help.
This is not the first patient I've sent home prescription-less. But it's the first time I've thought about it this way. In the past, I might've said to myself, the patient doesn't meet criteria, and therefore doesn't have the disorder in question, and consequently won't benefit from medication for this condition.
But now I'm reminded of the joke about the philosophy exam question, asking students to describe the physical characteristics of the chair at the front of the room. One student's response: What chair?
What disorder?
I came up with the following analogy: Suppose I decide that people who have more than 5 bad hair days per month carry a diagnosis of BHDD (Bad Hair Day Disorder). Am I describing an entity? Yes, people who have too many bad hair days. Does that make it a disorder, or disease?
I'm not sure the analogy is valid. At least some of the DSM diagnoses have a basis in clinical experience.
The truth is, and I realized this while I was writing, that I do find the DSM criteria for MDD useful, as a line of questioning.
This patient did not fit into any nice little DSM category. And I didn't try to make her fit. My thinking was, let's explore what she's been experiencing, using DSM criteria as a starting point. And that was useful.
I haven't purchased a copy of DSM-5. I don't want to. And I resent that, despite all the protests to the contrary, it remains the "bible" of psychiatry, and decisions are made based on its contents-reimbursement decisions, legal decisions.
But I do wish it could be what it professes to be: a guideline. Then it could sit on my book shelf with all the other books I use as references and guidelines, not with pride of place, and not with shame, either.
Friday, June 7, 2013
Learning from Diabetes
In a recent post, I wrote about how 126 became the cutoff for diabetes. It turns out that it was my fantasy about how 126 became the cutoff for diabetes. In response to the post, I got an email with a link to an article about the diagnosis of DM, which is, in the words of the person who sent it, "eerily like stuff going around re the DSM." I can't vouch for the accuracy of the article, but I'll summarize briefly.
A long time ago, back in the 70's, there were multiple standards for diagnosing diabetes. The reason for the multiple standards was that if you graph the sugars of a varied population at any given time, some will be elevated, but those don't necessarily correspond to the people who have diabetes. Additionally, the graph never "jumps", so there's no clear cutoff point.
And at the time, there were limited treatments for diabetes, and essentially nothing to keep early type 2 from progressing. In addition, diabetes was quite stigmatized, and people with a diagnosis of DM could be refused health insurance, life insurance, employment, even a driver's license.
In 1978, the NIH convened a committee to establish a definition of diabetes, and the committee decided to place the cutoff higher than any standard had heretofore done, so that only people who unequivocally had DM would be given the diagnosis, and people who couldn't be helped anyway, such as early type 2 diabetics, would be spared the stigma, and its practical consequences.
And since a graph of a general population did not have a clear cut off point for DM, the committee looked at a subculture, the Pima Indians, whose graph did make a jump. Those Pima Indians whose Oral Glucose Tolerance Test was under 200 showed no symptoms of retinopathy, and those who did show signs of retinopathy had OGTT's over 240.
Then the committee decided to put the cutoff for fasting glucose at 140, higher than that of the typical diabetic Pima Indian, whose fasting glucose would hover around 120. Presumably this was done because at the time, OGTT was the test expected to be used to make a diagnosis, not fasting glucose.
In 1995, another committee was convened to re-examine the decision of the 1978 committee. This committee decided to use fasting glucose as the diagnostic test, presumably because it was cheaper, and it used a cutoff of 126, even though 121 seems to correspond with an OGTT of 200. They went with the highest number they could find in any study, specifically, a study of 13 Pacific populations.
There's more to the saga, but I'm gonna stop here with the diabetes. The take-home lesson for me is, Psychiatry is not such an outlier.
There are groups of people, including Gary Greenberg and his Book of Woe, who claim that Psychiatry is not as scientifically based as other medical specialties. Then there are other groups that claim it is scientific. Well, it appears to be at least as scientific as endocrinology.
A known disease entity, no one definitive diagnostic system, definition of disease determined by committee based on dubious scientific conclusions, the political stance not to further stigmatize people suffering from the disease, and a subsequent committee that examined the problems with the first committee's decisions, and then went on to make its own, new mistakes.
There is nothing new under the sun. A generation passes, and the world remains the same.
Read the article. It'll spook you. Even if it isn't accurate, it's exactly the same kind of rhetoric taking place now, about DSM-5.
A long time ago, back in the 70's, there were multiple standards for diagnosing diabetes. The reason for the multiple standards was that if you graph the sugars of a varied population at any given time, some will be elevated, but those don't necessarily correspond to the people who have diabetes. Additionally, the graph never "jumps", so there's no clear cutoff point.
And at the time, there were limited treatments for diabetes, and essentially nothing to keep early type 2 from progressing. In addition, diabetes was quite stigmatized, and people with a diagnosis of DM could be refused health insurance, life insurance, employment, even a driver's license.
In 1978, the NIH convened a committee to establish a definition of diabetes, and the committee decided to place the cutoff higher than any standard had heretofore done, so that only people who unequivocally had DM would be given the diagnosis, and people who couldn't be helped anyway, such as early type 2 diabetics, would be spared the stigma, and its practical consequences.
And since a graph of a general population did not have a clear cut off point for DM, the committee looked at a subculture, the Pima Indians, whose graph did make a jump. Those Pima Indians whose Oral Glucose Tolerance Test was under 200 showed no symptoms of retinopathy, and those who did show signs of retinopathy had OGTT's over 240.
Then the committee decided to put the cutoff for fasting glucose at 140, higher than that of the typical diabetic Pima Indian, whose fasting glucose would hover around 120. Presumably this was done because at the time, OGTT was the test expected to be used to make a diagnosis, not fasting glucose.
In 1995, another committee was convened to re-examine the decision of the 1978 committee. This committee decided to use fasting glucose as the diagnostic test, presumably because it was cheaper, and it used a cutoff of 126, even though 121 seems to correspond with an OGTT of 200. They went with the highest number they could find in any study, specifically, a study of 13 Pacific populations.
There's more to the saga, but I'm gonna stop here with the diabetes. The take-home lesson for me is, Psychiatry is not such an outlier.
There are groups of people, including Gary Greenberg and his Book of Woe, who claim that Psychiatry is not as scientifically based as other medical specialties. Then there are other groups that claim it is scientific. Well, it appears to be at least as scientific as endocrinology.
A known disease entity, no one definitive diagnostic system, definition of disease determined by committee based on dubious scientific conclusions, the political stance not to further stigmatize people suffering from the disease, and a subsequent committee that examined the problems with the first committee's decisions, and then went on to make its own, new mistakes.
There is nothing new under the sun. A generation passes, and the world remains the same.
Read the article. It'll spook you. Even if it isn't accurate, it's exactly the same kind of rhetoric taking place now, about DSM-5.
Wednesday, June 5, 2013
Show Me The Science
I got this email yesterday:
NYSPA E-ALERT: CONTACT YOUR LEGISLATOR TODAY REGARDING AUTISM BILL
All members are strongly encouraged to contact their local Assembly member or Senator today to oppose the passage of S.3044-A (Carlucci)/A.1663-A (Abinanti), a bill that would amend the Insurance Law and the Mental Hygiene Law to codify the DSM-IV definition of autism as the official definition of autism for the purposes of New York State law. The proponents of the legislation seek to freeze the definition of autism because they are fearful that the new definitions in DSM-5 may diminish or eliminate eligibility for special education services in schools and/or health insurance coverage for community services. This is simply not true and would be an improper intrusion of the Legislature into the realm of medical science. Medical professionals must have the ability to update and revise clinical diagnoses according to new scientific evidence and advances in medicine.
I'm gonna ignore, for now, the topic of what role the government should play in medicine, and focus on that last sentence: Medical professionals must have the ability to update and revise clinical diagnoses according to new scientific evidence and advances in medicine.
Nu, so show me the science.
According to the DSM-5 description of the changes in criteria for Autism Spectrum Disorder:
The DSM-5 criteria were tested in real-life clinical settings as part of DSM-5 field trials, and analysis from that testing indicated that there will be no significant changes in the prevalence of the disorder. More recently, the largest and most up-to-date study, published by Huerta, et al, in the October 2012 issue of American Journal of Psychiatry, provided the most comprehensive assessment of the DSM-5 criteria for ASD based on symptom extraction from previously collected data. The study found that DSM-5 criteria identified 91 percent of children with clinical DSM-IV PDD diagnoses, suggesting that most children with DSM-IV PDD diagnoses will retain their diagnosis of ASD using the new criteria. Several other studies, using various methodologies, have been inconsistent in their findings.
There didn't seem to be any reference or link to the "real-life clinical settings", and it seems like, if a "real-life" study was done, it would have been published, or pending publication, at least cited. But I did check out the Huerta paper, published in October, 2012. Here's the method:
Three data sets included 4,453 children with DSM-IV clinical PDD diagnoses and 690 with non-PDD diagnoses (e.g., language disorder). Items from a parent report measure of ASD symptoms (Autism Diagnostic Interview-Revised) and clinical observation instrument (Autism Diagnostic Observation Schedule) were matched to DSM-5 criteria and used to evaluate the sensitivity and specificity of the proposed DSM-5 criteria and current DSM-IV criteria when compared with clinical diagnoses.
I don't really understand what was done, and I'm not paying for the full article to figure it out.
These were the results:
Based on just parent data, the proposed DSM-5 criteria identified 91% of children with clinical DSM-IV PDD diagnoses. Sensitivity remained high in specific subgroups, including girls and children under 4. The specificity of DSM-5 ASD was 0.53 overall, while the specificity of DSM-IV ranged from 0.24, for clinically diagnosed PDD not otherwise specified (PDD-NOS), to 0.53, for autistic disorder. When data were required from both parent and clinical observation, the specificity of the DSM-5 criteria increased to 0.63.
Okay, sensitivity 91% or less ("remained high"), specificity 0.53 to 0.63. I'm a little confused. You have 100 patients who were diagnosed with DSM-4 PDD, and 91 of them were diagnosed with DSM-5 ASD. Normally, you would use a sensitivity of 91% to establish that the new standard you're proposing is adequate, since it's almost as good as the old standard. So the diagnostic standard you're comparing to is DSM-4, and you're saying that since DSM-5 is almost as good as DSM-4, it's better than DSM-4.
What would make sense is if there were a third standard, the Autism Standard, which was the basis for diagnosing Autism. If DSM-4 had, say, 80% sensitivity, and DSM-5 had 91% sensitivity, compared with the Autism Standard, then you could conclude that DSM-5 was more sensitive than DSM-4.
Alternatively, if they're saying that DSM-5 only picked up 91% of cases because 9% of DSM-4 cases are inaccurately diagnosed, then you need to question the basis for DSM-4 criteria, so you can't use it as a standard to compare DSM-5 to.
To belabor the point: Suppose you're testing lexapro vs. prozac, and comparing both to nortriptyline. If lexapro helped 80% of patients who were helped by nortriptyline, and prozac helped 95% of patients helped by nortriptyline, you could reasonably conclude that prozac works better than lexapro. But if you compare lexapro directly with prozac, and you find that lexapro helps 91 of the 100 patients that were helped by prozac, you can't conclude that lexapro works better than prozac.
And if you then claim that lexapro does work better than prozac because prozac didn't really help all the 100 people it claims to have helped, then you have no idea what prozac does and doesn't do, so what does it mean to say lexapro works better?
See what I'm getting at?
You could argue that DSM-5 has better specificity than DSM-4, but the whole concern is that people who have a DSM-4 diagnosis of PDD won't all have a DSM-5 diagnosis of ASD, so some will lose needed services/treatment. So the concern is about missing a real case, not misdiagnosing someone who doesn't have PDD. In other words, specificity isn't the issue.
Moving right along.
I looked up some of those "other studies" that have been "inconsistent in their findings".
This study, by McPartland, et al, published in April, 2012, found these results:
When applying proposed DSM-5 diagnostic criteria for ASD, 60.6% (95% confidence interval: 57%-64%) of cases with a clinical diagnosis of an ASD met revised DSM-5 diagnostic criteria for ASD. Overall specificity was high, with 94.9% (95% confidence interval: 92%-97%) of individuals accurately excluded from the spectrum. Sensitivity varied by diagnostic subgroup (autistic disorder = 0.76; Asperger's disorder = 0.25; pervasive developmental disorder-not otherwise specified = 0.28) and cognitive ability (IQ < 70 = 0.70; IQ ≥ 70 = 0.46).
The study concludes that:
Proposed DSM-5 criteria could substantially alter the composition of the autism spectrum. Revised criteria improve specificity but exclude a substantial portion of cognitively able individuals and those with ASDs other than autistic disorder. A more stringent diagnostic rubric holds significant public health ramifications regarding service eligibility and compatibility of historical and future research.
Another study found lower sensitivity and greater specificity, with sensitivity improving, although still less than DSM-4, if one DSM-5 criterion was relaxed.
Yet another study found lower sensitivity.
Let's see. We have "real-life" clinical settings without a linked study. We have one cited study demonstrating that some of the people with DSM-4 PDD diagnoses would lose those diagnoses under DSM-5, we have a statement that, "This is simply not true," and we have a sneaky little sentence dismissing, and not citing, those "other studies".
No, I don't think I will be contacting my local assembly member or senator.
NYSPA E-ALERT: CONTACT YOUR LEGISLATOR TODAY REGARDING AUTISM BILL
All members are strongly encouraged to contact their local Assembly member or Senator today to oppose the passage of S.3044-A (Carlucci)/A.1663-A (Abinanti), a bill that would amend the Insurance Law and the Mental Hygiene Law to codify the DSM-IV definition of autism as the official definition of autism for the purposes of New York State law. The proponents of the legislation seek to freeze the definition of autism because they are fearful that the new definitions in DSM-5 may diminish or eliminate eligibility for special education services in schools and/or health insurance coverage for community services. This is simply not true and would be an improper intrusion of the Legislature into the realm of medical science. Medical professionals must have the ability to update and revise clinical diagnoses according to new scientific evidence and advances in medicine.
I'm gonna ignore, for now, the topic of what role the government should play in medicine, and focus on that last sentence: Medical professionals must have the ability to update and revise clinical diagnoses according to new scientific evidence and advances in medicine.
Nu, so show me the science.
According to the DSM-5 description of the changes in criteria for Autism Spectrum Disorder:
The DSM-5 criteria were tested in real-life clinical settings as part of DSM-5 field trials, and analysis from that testing indicated that there will be no significant changes in the prevalence of the disorder. More recently, the largest and most up-to-date study, published by Huerta, et al, in the October 2012 issue of American Journal of Psychiatry, provided the most comprehensive assessment of the DSM-5 criteria for ASD based on symptom extraction from previously collected data. The study found that DSM-5 criteria identified 91 percent of children with clinical DSM-IV PDD diagnoses, suggesting that most children with DSM-IV PDD diagnoses will retain their diagnosis of ASD using the new criteria. Several other studies, using various methodologies, have been inconsistent in their findings.
There didn't seem to be any reference or link to the "real-life clinical settings", and it seems like, if a "real-life" study was done, it would have been published, or pending publication, at least cited. But I did check out the Huerta paper, published in October, 2012. Here's the method:
Three data sets included 4,453 children with DSM-IV clinical PDD diagnoses and 690 with non-PDD diagnoses (e.g., language disorder). Items from a parent report measure of ASD symptoms (Autism Diagnostic Interview-Revised) and clinical observation instrument (Autism Diagnostic Observation Schedule) were matched to DSM-5 criteria and used to evaluate the sensitivity and specificity of the proposed DSM-5 criteria and current DSM-IV criteria when compared with clinical diagnoses.
I don't really understand what was done, and I'm not paying for the full article to figure it out.
These were the results:
Based on just parent data, the proposed DSM-5 criteria identified 91% of children with clinical DSM-IV PDD diagnoses. Sensitivity remained high in specific subgroups, including girls and children under 4. The specificity of DSM-5 ASD was 0.53 overall, while the specificity of DSM-IV ranged from 0.24, for clinically diagnosed PDD not otherwise specified (PDD-NOS), to 0.53, for autistic disorder. When data were required from both parent and clinical observation, the specificity of the DSM-5 criteria increased to 0.63.
Okay, sensitivity 91% or less ("remained high"), specificity 0.53 to 0.63. I'm a little confused. You have 100 patients who were diagnosed with DSM-4 PDD, and 91 of them were diagnosed with DSM-5 ASD. Normally, you would use a sensitivity of 91% to establish that the new standard you're proposing is adequate, since it's almost as good as the old standard. So the diagnostic standard you're comparing to is DSM-4, and you're saying that since DSM-5 is almost as good as DSM-4, it's better than DSM-4.
What would make sense is if there were a third standard, the Autism Standard, which was the basis for diagnosing Autism. If DSM-4 had, say, 80% sensitivity, and DSM-5 had 91% sensitivity, compared with the Autism Standard, then you could conclude that DSM-5 was more sensitive than DSM-4.
Alternatively, if they're saying that DSM-5 only picked up 91% of cases because 9% of DSM-4 cases are inaccurately diagnosed, then you need to question the basis for DSM-4 criteria, so you can't use it as a standard to compare DSM-5 to.
To belabor the point: Suppose you're testing lexapro vs. prozac, and comparing both to nortriptyline. If lexapro helped 80% of patients who were helped by nortriptyline, and prozac helped 95% of patients helped by nortriptyline, you could reasonably conclude that prozac works better than lexapro. But if you compare lexapro directly with prozac, and you find that lexapro helps 91 of the 100 patients that were helped by prozac, you can't conclude that lexapro works better than prozac.
And if you then claim that lexapro does work better than prozac because prozac didn't really help all the 100 people it claims to have helped, then you have no idea what prozac does and doesn't do, so what does it mean to say lexapro works better?
See what I'm getting at?
You could argue that DSM-5 has better specificity than DSM-4, but the whole concern is that people who have a DSM-4 diagnosis of PDD won't all have a DSM-5 diagnosis of ASD, so some will lose needed services/treatment. So the concern is about missing a real case, not misdiagnosing someone who doesn't have PDD. In other words, specificity isn't the issue.
Moving right along.
I looked up some of those "other studies" that have been "inconsistent in their findings".
This study, by McPartland, et al, published in April, 2012, found these results:
When applying proposed DSM-5 diagnostic criteria for ASD, 60.6% (95% confidence interval: 57%-64%) of cases with a clinical diagnosis of an ASD met revised DSM-5 diagnostic criteria for ASD. Overall specificity was high, with 94.9% (95% confidence interval: 92%-97%) of individuals accurately excluded from the spectrum. Sensitivity varied by diagnostic subgroup (autistic disorder = 0.76; Asperger's disorder = 0.25; pervasive developmental disorder-not otherwise specified = 0.28) and cognitive ability (IQ < 70 = 0.70; IQ ≥ 70 = 0.46).
The study concludes that:
Proposed DSM-5 criteria could substantially alter the composition of the autism spectrum. Revised criteria improve specificity but exclude a substantial portion of cognitively able individuals and those with ASDs other than autistic disorder. A more stringent diagnostic rubric holds significant public health ramifications regarding service eligibility and compatibility of historical and future research.
Another study found lower sensitivity and greater specificity, with sensitivity improving, although still less than DSM-4, if one DSM-5 criterion was relaxed.
Yet another study found lower sensitivity.
Let's see. We have "real-life" clinical settings without a linked study. We have one cited study demonstrating that some of the people with DSM-4 PDD diagnoses would lose those diagnoses under DSM-5, we have a statement that, "This is simply not true," and we have a sneaky little sentence dismissing, and not citing, those "other studies".
No, I don't think I will be contacting my local assembly member or senator.
Monday, May 27, 2013
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.
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.
Friday, May 24, 2013
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
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.
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