Adding the MDD diagnosis

[F0nzie]

I have been having a hard time getting approval for brand name antidepressants even with multiple failed trials when the diagnosis is Schizoaffective disorder or Bipolar disorder. Psychosis and mania are in check with mood stabilizers and antipsychotics but they are in full blown depression. I get the rejection "no studies supporting treatment of Schizoaffective/Bipolar disorder". But they do meet criteria for MDD...its just seems redundant to add it to their diagnosis. Should I just add MDD to their primary diagnosis and run the prior auth again?

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[nexus73]

If I learned anything from House of God, the answer is yes. I got a denial for a bipolar type 2 diagnosis saying the medicine isn't FDA approved, but guess what nothing is approved for bipolar 2.

 

[shan564]

What if you call it unspecified depression?

Regarding schizoaffective... the DSM-5 made that a bit more generous anyway. You have to be in a mood episode for >50% of the duration of the illness to qualify for the diagnosis, so many of the people who previously met the schizoaffective criteria will now be schizophrenia + MDD. I feel like it's hard to prove that somebody has major depression for >50% of the duration of the psychotic illness, so you can call it schizophrenia + MDD until you confirm that. The DSM-5 also adds a bit to say that the schizoaffective diagnosis is supposed to be rare.

 

[smalltownpsych]

Schizoaffective probably is rare and the research continues to point to that which is why DSM-IV said that as well. Unfortunately, the dx is handed out as if it was a common occurrence. Even Bipolar tends to be diagnosed much higher than what the stats say it should be. Borderline Personality Disorder on the other hand is 20 percent of inpatient population and 10 percent of outpatient and substance abusers are pretty common too and they have lots of symptoms but never seem to fit the criteria or treatment well. I guess what I am saying is I see patients every day from one or other of these two diagnostic categories being misdiagnosed as Schizoaffective or maybe Bipolar. Base rates can be a good guide in improving diagnostic accuracy or as they say think horses not zebras. I always want to know how severe the psychosis really was and if it occurs in the absence of intoxicants before being fully convinced of these more severe diagnoses, especially when I see relatively normal interpersonal functioning and behaviors when patient is not agitated.

 

[Doctor Bagel]

Schizoaffective probably is rare and the research continues to point to that which is why DSM-IV said that as well. Unfortunately, the dx is handed out as if it was a common occurrence. Even Bipolar tends to be diagnosed much higher than what the stats say it should be. Borderline Personality Disorder on the other hand is 20 percent of inpatient population and 10 percent of outpatient and substance abusers are pretty common too and they have lots of symptoms but never seem to fit the criteria or treatment well. I guess what I am saying is I see patients every day from one or other of these two diagnostic categories being misdiagnosed as Schizoaffective or maybe Bipolar. Base rates can be a good guide in improving diagnostic accuracy or as they say think horses not zebras. I always want to know how severe the psychosis really was and if it occurs in the absence of intoxicants before being fully convinced of these more severe diagnoses, especially when I see relatively normal interpersonal functioning and behaviors when patient is not agitated.

I think 99% of the patients I inherited in my community job had a schizoaffective disorder diagnosis in their chart. I took that to mean they have a mental illness of some sort that is somewhat severe.

 

[smalltownpsych]

On a related note, I saw a patient yesterday that might just be the first real Bipolar II patient I have ever seen in over ten years of training and working. Literally every patient I have ever worked with who had a prior diagnosis of Bipolar II was clearly misdiagnosed. Substance abuse disorder, Borderline personality, adjustment disorder, anxiety disorder, depressive disorders, ADHD., you name it. I need to give the NP some credit this time, although could be just the broken clock phenomenon.

 

[HarryMTieboutMD]

Schizoaffective disorder needs to go away... entirely. As long as we have categorial diagnoses the Kraepelinian Dichotomy (with obvious limitations) works well enough if you just look at longitudinal course and issue while realizing that schizophrenics have periods of mania and depression, and florid psychosis in a severe bipolar patient who is manic can overwhelm the "checklist mania" systems until it has been treated. Sorry for the rant, but I hate SAD and refuse to diagnose it!

 

[notdeadyet]

Schizoaffective disorder needs to go away... entirely.

I think it has its place.

I don't think the problem is so much with the diagnosis as with the diagnoser.

 

[Shikima]

I think it has its place.

I don't think the problem is so much with the diagnosis as with the diagnoser.

Just like Bipolar diagnosis for all psych admits and consults.

 

[nitemagi]

On a related note, I saw a patient yesterday that might just be the first real Bipolar II patient I have ever seen in over ten years of training and working. Literally every patient I have ever worked with who had a prior diagnosis of Bipolar II was clearly misdiagnosed. Substance abuse disorder, Borderline personality, adjustment disorder, anxiety disorder, depressive disorders, ADHD., you name it. I need to give the NP some credit this time, although could be just the broken clock phenomenon.

I undiagnosed it all the time. Occasionally I'm surprised though, by people who are just poor historians and don't remember their hypomanic episode. It's only when I get clear ER records or they have another episode that it all becomes clear.

 

[notdeadyet]

Just like Bipolar diagnosis for all psych admits and consults.

Yup. Bipolar seems to be the diagnosis of choice for folks that don't think men can be Borderline too...


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[st2205]

I undiagnosed it all the time. Occasionally I'm surprised though, by people who are just poor historians and don't remember their hypomanic episode. It's only when I get clear ER records or they have another episode that it all becomes clear.

This is why I find screening for bipolar (unless with a collateral historian) rather useless -- if you've never been manic, chances are you'll say you have been but it won't hold up on any digging; if you've been manic, you're rather insightless and screen negative. There will periodically be holes in people's stories that make me question bipolar, such as having hospital admissions they can't explain (or only explain superficially "I wasn't doing well")... or taking a history and them denying any previous treatment only to have them later detail why they can't take something like Risperdal because they've had problems with it in the past.