Can we get to the bottom of the Autism thing?

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Anasazi23

Anasazi23

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There have been other threads on this, but none that I remember in recent memory that addressed the unbelievable epidemic that is now occurring in the U.S.

Every day I'm bombarded with newsletters from psychiatric organizations which herald what appears to be a nation full of autistic people.

The U.S. at this moment has about 301,139,947 people. The current birth rate is 14.16/1000 annually. Very crudely, not taking into account the death rate change, ageing population, and ethinic shifts, this means that next year there will be about 4.2 million new births. At the cited rate by the APA, we can expect about 28,467 NEW autistic cases next year.

This is an epidemic.

Delaying vaccines, refusing all vaccines, and other strategies don't seem to be helping thus far, and parents are petrified that they'll bring their baby home from the pediatrician's office - literally a different person.

In fact, the vaccine theory is hotly debated, both in the scientific and popular press. At the end of nearly all of those articles, the ending paragraph is similar: "Know the risks, make an informed choice," which is nearly useless advice.

Should we be talking about vaccines and their relation to autism at all? Is there some yet unforseen factor contributing to this?

Imagining the U.S. with 1/90 - 1/150 autistic folks 20 years from now sounds like a very concerning place.
 
It also depends on how you're defining autism. It used to be quite severe "Rainman" type pathology, but now it seems that most of the Dept. of Pathology would meet criteria. 😉
 
Ecclesiastes 1:9
 
Doc Samson said:
It also depends on how you're defining autism. It used to be quite severe "Rainman" type pathology, but now it seems that most of the Dept. of Pathology would meet criteria. 😉
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I think you make a good point.

Perusing such things as parenting websites reveal that now if your baby is afraid of the vacuum cleaner, they have "sensory integration disorder" which is of course on the PDD spectrum.
 
i also thought that talks about vaccines and autism is pretty much over with, can you please provide a link for the new info that you have. thanks in advance..😀
 
You mean your baby doesn't like the roaring obnoxious sound of the unfamiliar vacuum? I can't stand the sound of the vacuum either, which is exactly why I don't vacuum - ever. 😎

Your baby's fine. 🙂
 
Anasazi23 said:
You mean your baby doesn't like the roaring obnoxious sound of the unfamiliar vacuum? I can't stand the sound of the vacuum either, which is exactly why I don't vacuum - ever. 😎

Your baby's fine. 🙂
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Great - I can reassure Mrs. DS that he'll grow up to be just like 'Sazi (might not show her those LOTRO posts though). 😉
 
From APA Headlines:

Heightened autism awareness leading to wariness of vaccines, pediatricians say.
In continuing coverage from previous editions of Headlines, New Jersey's Star-Ledger (7/20, O'Brien) reported, "With autism spectrum disorders now diagnosed in one out of 150 children nationally, and one in 94 in New Jersey, rare is the parent who isn't aware of autism." And, with heightened awareness "come a new wariness of vaccines, which a vocal minority of autism activists blame for the jump in cases. Pediatricians report seeing more parents question, delay, or even shun altogether the traditional round of childhood immunizations." Further complicating the situation "are celebrities who either blame or suspect vaccines, such as actress Jenny McCarthy, and radio talk show host Don Imus. Doctors complain they get an unquestioning ride in the media." While the prevalence of autism "has soared in recent years, experts are unsure whether more cases are occurring, or simply more cases are being diagnosed." The UPI (7/21) reprised the Star-Ledger's coverage of the story.
Study indicates caring for children with autism, Down's syndrome may weaken parents' immune system. The BBC (7/19) reported, "Caring for children with developmental problems, such as autism or Down's syndrome, can weaken parents' immune systems," according to a study published in the journal Brain, Behavior, and Immunity. In the study, Stephen Gallagher, M.Sc., of the U.K.'s Birmingham University, and colleagues, administered pneumococcal vaccine to "a total of 60 parents,...half of whom had children with developmental disabilities." By examining the results of blood tests, the researchers found that parents "caring for a child with developmental disability had lower levels of antibodies to the vaccine than those whose children did not have such difficulties." For example, "[a]fter one month, 20 percent of parents providing long-term care had an ineffective immune response, compared to four percent of the control group. At six months, this had risen to 48 percent, while the levels in the control group remained the same." Gallagher attributed stress as the agent most likely "responsible for the immune deficiency."
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Doc Samson said:
It also depends on how you're defining autism. It used to be quite severe "Rainman" type pathology, but now it seems that most of the Dept. of Pathology would meet criteria. 😉
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When did a diagnosis of autism change to a diagnosis of being within the "autism spectrum"? Wouldn't this account in part for the increase in diagnoses?
 
I think there are several things at play:
1) Increased diagnosis with less than rigorous diagnostic criteria application. I've worked in peds neurology offices where it's a diagnosis of impression - "He looks autistic and parents seem concerned. So I'm giving him the diagnosis so they can get intensive services." I currently work in a clinic where we do the ADI-R and ADOS, as well as medical and genetic work-up before providing a diagnosis. Yet at the same time, parents can come away unsatisfied because they wanted a label so they could get the same 30hr/wk ABA programming the parent on the online BB for ASD raves about.
2) Assortative mating. My spouse used to teach at a engineering school and he had a number of students who were Asperger's or near-Asperger's, and were dating other engineering students with similar levels of social dysfunction. Sadly, we see this in a number of our clinic kids with Autism - Mom and Dad met in graduate school for math or engineering and had kids, all with ASD spectrum disorders.
 
From my good friend Michael Savage, via the APA Headlines (see? I told you I'm bombarded with this stuff).

Radio host defends remarks about autism.
The New York Times (7/22, E2, Steinberg) reports that in a telephone interview on Monday, "Michael Savage, the incendiary radio host who last week characterized nearly every child with autism as 'a brat who hasn't been told to cut the act out,' said...that he stood by his remarks, and had no intention of apologizing to those advocates and parents who have called for his firing over the matter." After calling autism "an overdiagnosed medical condition," Savage said that "he was proud to have prodded discussion on the subject, and planned to give over his entire show on Monday...to parents and other callers who wished to disagree with him and to educate him."
According to the AP (7/22, Bauder), "Some parents of autistic children have called for Savage's firing after he described autism as a racket last week." Savage, however, "offered no apology in a message posted Monday on his website." Instead, "[h]e said greedy doctors and drug companies were creating a 'national panic' by over-diagnosing autism, a mental disorder that inhibits a person's ability to communicate." On his July 16 "Savage Nation" show, the radio show host said that children with autism "don't have a father around to tell them, 'Don't act like a *****. You'll get nowhere in life. Stop acting like a putz. Straighten up. Act like a man. Don't sit there crying and screaming, you idiot.'"
New York's Newsday (7/22, Polsky) added that Savage's "controversial remarks drove several dozen parents and advocates Monday to protest outside" radio station WOR-710's Manhattan offices. Demonstration organizer Evelyn Ain, the mother of an eight-year-old son with autism, said of Savage's remarks, "That isn't just freedom of speech, it is hateful speech when you say 99 percent of children with autism are brats." She added, "I'll tell you, I wish I had a brat."
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MBK2003 said:
Sadly, we see this in a number of our clinic kids with Autism - Mom and Dad met in graduate school for math or engineering and had kids, all with ASD spectrum disorders.
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I think these doctorate degree holding parents might just be more perceptive of their childrens' problems and also more financially able to get them checked out. Most people don't even know Asperger's exists. The undeducated will treat their children in Michael Savage fashion, "Don't act like a *****. Stop acting like a putz. Straighten up. Act like a man. Don't sit there crying and screaming, idiot." 🙄
 
Savage
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Was listening to Savage today--something I didn't think I'd be able to do again since he was taken down in my previous area. Wow has he changed from the last time I heard him--not that much yelling. I was actually agreeing with a lot of what he was saying.

He too mentioned the strange rise in this disorder.

Take your pic--increased awareness, over (& mis) diagnosis, something strange possibly causing it or a combination of several factors.

Only factors I can think of that may have increased it (& this is pure speculation) is that 1-there's more & more jobs with increased exposure to radiation at subclinical levels. 2) there has been a link with autism & advanced paternal age--has the average age of a father gone up?
 
Michael Savage thrives on being controversial...he is the ultimate troll.
 
grandslam521 said:
Michael Savage thrives on being controversial...he is the ultimate troll.
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I'd agree to an extent, but he also seems to have the cajones to actually say what a lot of people think instead of playing the "Media Watlz" around the actual subject.

Savage is so refreshing in a world of newscasters that send me off rolling my eyes 🙄 as I watch them to try to report on a news story that doesn't meet all standards of PC excellence.

He'll dive off the deepend every now and then, but all too often I find myself agreeing with him. The angry man on the radio.... Anderson Cooper he ain't. :laugh:
 
An attending I had as a resident mentioned to me that when Prozac came out, "everybody" (of course not literally everybody, just a lot more than should've) were put on it. It was the first SSRI & Lilly knew it had a goldmine on its hands & advertised this baby as much as it could.

He mentioned patients not being depressed & then put on it, & then saying something to the effect of, "I never knew I was depressed, but now I'm on Prozac, I feel so much better & I guess I really was depressed after all", among several other ridiculous comments.

Then after the media & public lovefest finally ended, the shift went against prozac starting with the postal worker killings shifting the public favor the other way.

His point was whenever the public becomes very aware of a mental health issue due to a media blitz (actually I've seen the same with medical issues in general such as as freakin anthrax scare & everyone taking Cipro), they go to polarized extremes in their perception of this.

If this is going on with Autism--then what's going to happen is in a few years, provided that this autism overflux is not based on anything real, we're going to see a bunch of overdiagnosed cases and then what's going to happen is people are going to blame psychiatry.

For completely selfish reasons--its best to practice psychiatry honestly & objectively. While I'm not exactly Savage's biggest fan (though I do find his comments refreshing from time to time), I agree that his argument is worth considering.

His stance was that Autism truly is an existing disorder, & those who truly have it deserve our care & funding. However because of behavioral criteria used to diagnose it, which have been rendered too subjective because we're now looking at it as a spectrum, and because the medical infrastructure demands billing & medication, its likely that several are being misdiagnosed in the name of getting a billing, then put on a med because the insurance company requires that for the payment to go in effect.

A scenario I've seen before with other disorders--and this applies across the medical spectrum, including psychiatry, but also other fields. I call it "fast food medicine".

I do not know if misdiagnosis is the true culprit for the dramatic rise, but it is worth considering, and if it truly is the cause, then it should be nipped in the bud ASAP.
 
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whopper said:
An attending I had as a resident mentioned to me that when Prozac came out, "everybody" (of course not literally everybody, just a lot more than should've) were put on it. It was the first SSRI & Lilly knew it had a goldmine on its hands & advertised this baby as much as it could.

He mentioned patients not being depressed & then put on it, & then saying something to the effect of, "I never knew I was depressed, but now I'm on Prozac, I feel so much better & I guess I really was depressed after all", among several other ridiculous comments.

Then after the media & public lovefest finally ended, the shift went against prozac starting with the postal worker killings shifting the public favor the other way.

His point was whenever the public becomes very aware of a mental health issue due to a media blitz (actually I've seen the same with medical issues in general such as as freakin anthrax scare & everyone taking Cipro), they go to polarized extremes in their perception of this.

If this is going on with Autism--then what's going to happen is in a few years, provided that this autism overflux is not based on anything real, we're going to see a bunch of overdiagnosed cases and then what's going to happen is people are going to blame psychiatry.

For completely selfish reasons--its best to practice psychiatry honestly & objectively. While I'm not exactly Savage's biggest fan (though I do find his comments refreshing from time to time), I agree that his argument is worth considering.

His stance was that Autism truly is an existing disorder, & those who truly have it deserve our care & funding. However because of behavioral criteria used to diagnose it, which have been rendered too subjective because we're now looking at it as a spectrum, and because the medical infrastructure demands billing & medication, its likely that several are being misdiagnosed in the name of getting a billing, then put on a med because the insurance company requires that for the payment to go in effect.

A scenario I've seen before with other disorders--and this applies across the medical spectrum, including psychiatry, but also other fields. I call it "fast food medicine".

I do not know if misdiagnosis is the true culprit for the dramatic rise, but it is worth considering, and if it truly is the cause, then it should be nipped in the bud ASAP.
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If what you say does happen, who else could be blamed but those doing the over-diagnosing....

"For completely selfish reasons--its best to practice psychiatry honestly & objectively." You really hit the nail on the head here. In other posts there were discussions about Big Pharma's cozy relationships with "consulting" doctors, including psychiatrists. IMHO, all physicians (not just psychiatrists) should practice medicine honestly and objectively, the pharmaceutical salespeople be damned. I understand that with autism we're not really talking about prescribing medication (except when there are co-morbidity issues), but I do believe the notion of practicing honestly and objectively, and doing you're own homework, is the best practice as well as the best defense.
 
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HCE said:
If what you say does happen, who else could be blamed but those doing the over-diagnosing....

"For completely selfish reasons--its best to practice psychiatry honestly & objectively." You really hit the nail on the head here. In other posts there were discussions about Big Pharma's cozy relationships with "consulting" doctors, including psychiatrists. IMHO, all physicians (not just psychiatrists) should practice medicine honestly and objectively, the pharmaceutical salespeople be damned. I understand that with autism we're not really talking about prescribing medication (except when there are co-morbidity issues), but I do believe the notion of practicing honestly and objectively, and doing you're own homework, is the best practice as well as the best defense.
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This is more complex than it sounds. There are myriad reasons why a physician will attach a diagnosis when it may not be entirely warranted. This is in no way unique to psychiatry. Back in the day, when doctors were actually respected and were paid for their work and opinions, diagnosis was less important, and it was easier to practice objectively. Today, the lack of a diagnosis means that your 2 hour evaluation will go unpaid in its entirety by the insurance company. They don't consider the consultation, in many cases (not all), whereby you are working and using skills garnered in medical school and residency, to be worth paying for. The same occurs in family practice, and virtually every other medical discipline. It is in no way unique to psychiatry, and has nothing to do with drug reps.

Further, not providing a diagnosis for a child, in the case of PDD-type problems, means no services, no disability, no school accomodations...nothing. Parents don't want to hear this, and I don't blame them. Just as though you'll receive an antibiotic for benign ear pain even though countless studies show that it doesn't affect clinical outcome, psychiatrists will provide a diagnosis so that they can put food on the table, and help patients navigate a hostile insurance system.

If one were to read this board, or just read psych news or listen to Senate hearings, one might think that the field of medicine is saturated with evil-doing, money-grubbing, psychiatrists and other physicians who are rabidly shuffling patients through the door in-between golf games to make huge profits, and dining on steak dinners every night from pharm reps. In fact, I'd say that this is a small minority and that most psychiatrists work very hard for their patients, take countless phone calls and make countless provisions for their patients in order to get them good care. Contrary to what you may think, prescribing lexapro over celexa because you went to a dinner is not the end of the world, and it is taught in residency to become familiar with all options in treatment so that you're not stuck with zero experience when you do have to pull a new rabbit out of a treatment-resistant hat.

...on another note, I wonder when the government will get around to regulating the use of antibiotics, before we're all killed by the super-mutant strain of methicillin-resistant staphylococcus aureus that's currently brewing.
 
Anasazi23 said:
Further, not providing a diagnosis for a child, in the case of PDD-type problems, means no services, no disability, no school accomodations...nothing.
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Right... in some cases you don't know what the f@#$ is happening with the patient, but you know they're sick. If you don't make a diagnosis though, then all potential tx and services are denied - thus to do "the right thing" for your patient you "force" a diagnosis. Just look at how we use the GAF - no insurance will approve inpatient admission for a GAF >30 or outpatient for a GAF >70 (at least in MA), so the GAF has essentially become an indicator of what services the psychiatrist thinks the patient needs - inpatient gets ~25, outpatient gets ~65.
 
whopper said:
An attending I had as a resident mentioned to me that when Prozac came out, "everybody" (of course not literally everybody, just a lot more than should've) were put on it. It was the first SSRI & Lilly knew it had a goldmine on its hands & advertised this baby as much as it could.

He mentioned patients not being depressed & then put on it, & then saying something to the effect of, "I never knew I was depressed, but now I'm on Prozac, I feel so much better & I guess I really was depressed after all", among several other ridiculous comments.

Then after the media & public lovefest finally ended, the shift went against prozac starting with the postal worker killings shifting the public favor the other way.

His point was whenever the public becomes very aware of a mental health issue due to a media blitz (actually I've seen the same with medical issues in general such as as freakin anthrax scare & everyone taking Cipro), they go to polarized extremes in their perception of this.

If this is going on with Autism--then what's going to happen is in a few years, provided that this autism overflux is not based on anything real, we're going to see a bunch of overdiagnosed cases and then what's going to happen is people are going to blame psychiatry.

For completely selfish reasons--its best to practice psychiatry honestly & objectively. While I'm not exactly Savage's biggest fan (though I do find his comments refreshing from time to time), I agree that his argument is worth considering.

His stance was that Autism truly is an existing disorder, & those who truly have it deserve our care & funding. However because of behavioral criteria used to diagnose it, which have been rendered too subjective because we're now looking at it as a spectrum, and because the medical infrastructure demands billing & medication, its likely that several are being misdiagnosed in the name of getting a billing, then put on a med because the insurance company requires that for the payment to go in effect.

A scenario I've seen before with other disorders--and this applies across the medical spectrum, including psychiatry, but also other fields. I call it "fast food medicine".

I do not know if misdiagnosis is the true culprit for the dramatic rise, but it is worth considering, and if it truly is the cause, then it should be nipped in the bud ASAP.
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If only Savage would approach his arguments with the organization and simplicity that you do…instead he takes his premise and arguments, chops them up into little pieces, and shoots each piece at his audience with a Gatling gun. I know he is an entertainer, but he abuses his audience and demands to be taken seriously only when it is convenient for him. I realize this is mostly an ad hominem argument, but why should I listen to someone who consistently trying to confuse and manipulate his audience? Personally, I think his attack on medical diagnosis is just an extension of his arguments about the “de-masculization of males in America” or the regression of values in America. Unfortunately, he searches for the vulnerable, controversial, and convenient to serve as ridiculous examples for his cause.

By the way, I would never give my full attention to anyone who writes a book entitled The Complete Book of Homeopathy
 
I don't disagree with your criticisms of Savage, though I do find myself agreeing with him on the Autism issue.

It's not such a terrible thing when people who genuinely need services get services they need.
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But its also a terrible thing when someone not in need of services gets diagnosed & given a med that person does not need.

I agree with Anasazi & Doc Samson on the billing thing. Unfortunately, there's often times where you need to see a patient more & because of the darned structure managed care has given---YOU HAVE TO GIVE A DX.

If you got a Borderling patient who has cut herself, to the point where she could've died, and given that studies show that patients with parasuicidal behavior are at a significantly increased risk of suicide, are you going to dx that girl in the crisis psyche unit with No Axis I DO, Axis II Borderline, knowing that this will not get her into a psychiatry unit & get no payment?

(And on a side tangent, I hope the DSM V does put parasuicidal behavior in the Axis I category--because legally, you need an Axis I dx to get the patient billed on an inpatient unit).
 
Anasazi23 said:
Further, not providing a diagnosis for a child, in the case of PDD-type problems, means no services, no disability, no school accomodations...nothing. Parents don't want to hear this, and I don't blame them. Just as though you'll receive an antibiotic for benign ear pain even though countless studies show that it doesn't affect clinical outcome, psychiatrists will provide a diagnosis so that they can put food on the table, and help patients navigate a hostile insurance system.
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Anasazi, I agree with your argument in general, but the analogy falls down. When a primary care doc diagnoses "bronchitis", "otitis media", or
"pharyngitis", the reimbursement is the same whether he prescribes antibiotics or whether he tells the patient it is probably viral and prescribes supportive treatments (however, unfortunately it is a lot easier and quicker to prescribe abx). The insurance system is more hostile for psychiatric patients than medical patients.
 
michaelrack said:
Anasazi, I agree with your argument in general, but the analogy falls down. When a primary care doc diagnoses "bronchitis", "otitis media", or
"pharyngitis", the reimbursement is the same whether he prescribes antibiotics or whether he tells the patient it is probably viral and prescribes supportive treatments (however, unfortunately it is a lot easier and quicker to prescribe abx). The insurance system is more hostile for psychiatric patients than medical patients.
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The comment was speaking to the fact that prescribing an abx for a condition that doesn't need it may be considered poor practice or unethical, since one poster above made the assertion that doctors should practice "honestly and objectively." Yet, the general public doesn't mind this sort of practice. There are plenty of diagnoses that a PMD won't get paid for. So, they change the diagnosis to get paid.
 
Anasazi23 said:
There are plenty of diagnoses that a PMD won't get paid for. So, they change the diagnosis to get paid.
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Other than an a asympotmatic person coming in to get a form filled out, I can't think of any diagnoses that won't result in payment- most insurance companies will even accept non-specific symptoms such as snoring (786.09) or sleepiness (780.54), at least for an office visit (sometimes snoring isn't accepted for sleep study reimbursement). Can you give some examples of medical diagnoses that aren't accepted for reimbursement?
 
Axis II disorders will not get payment at the last hospital I was at--at least according to the 2 nurse managers & several attendings working there. Axis II DOs can get billing for outpatient from what I understand but not inpatient. This is important becuase a lot of borderlines do dangerous behavior that gets them on an inpatient unit.

Well, these patients do have a mood disturbance, although it may not fit a specific category, other than "Mood disorder NOS" which can be used.
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True...but parasuicidal behavior in a patient that has the criteria for borderline is a criteria for an Axis II disorder. Per NJ Commitment laws, you can't commit a patient based on an Axis II DO, & from the sources I mentioned above, there will be no reimbursement.

You are correct, but from an academic & diagnosis standpoint, if the person has Borderline, then shouldn't it be Borderline and not Mood DO NOS?
There is nothing as far as I can tell in the DSM saying that Borderline becomes Mood DO NOS with parasuicidal behavior. Nor anything that says Cluster B disorders become Mood disorders with emotional instability, which the manual acknowledges occurs in these patients & is part of their criterion for dx as a personality DO.

In the strictest sense, couldn't this be considered insurance fraud? Giving the patient a false dx to reap billing & benefits for the patient they wouldn't be eligible for with an honest dx?

This issue is silly & notes a problem in the system. Very few psychiatrists I know of will kick out a parasuicidal borderline from the psychiatric crisis unit who has done an action that was dangerous. Borderline patients with such behavior are documented to "up the ante" & are at increased risk of suicide.

From an ethical standpoint, they shouldn't either. If you're patient has done a dangerous act, due to a psychiatric disorder, one which is documented to put them at significant risk, shouldn't you do what you can to protect them & give them a safe discharge (which will probably take days to establish & cannot be done in a crisis center)?

Yet they are dx'd in a manner & billed that's not supposed to be done. Then the psychiatrist, knowing this happens, and who does not want to be the crusader who fixes this does not address the issue in the channels for psychiatrists such as their APA chapter or hospital administration because they don't want to be pointed out as manipulating the billing system.

Now maybe I'm missing something here because I got the baby DSM IV on me and re-read those sections to see if I missed something. Maybe the bigger DSM addresses this issue.

Getting back to the Autism thing, this is a reason why I believe Michael Savage may be on to something. I've seen several doctors give the old "depressive DO NOS" or "Mood DO NOS" for something which they even thought was an Axis II DO. Couldn't the same be going on with autism as a dx? Strange kid-they want more time to spend with the kid--so now they got to "cook" something up. Ahem---let's pick Autism! (And this is just my speculation).
 
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whopper said:
True...but parasuicidal behavior in a patient that has the criteria for borderline is a criteria for an Axis II disorder. Per NJ Commitment laws, you can't commit a patient based on an Axis II DO, & from the sources I mentioned above, there will be no reimbursement.

You are correct, but from an academic & diagnosis standpoint, if the person has Borderline, then shouldn't it be Borderline and not Mood DO NOS?
There is nothing as far as I can tell in the DSM saying that Borderline becomes Mood DO NOS with parasuicidal behavior. Nor anything that says Cluster B disorders become Mood disorders with emotional instability, which the manual acknowledges occurs in these patients & is part of their criterion for dx as a personality DO.
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As far as committments, if NJ law accepts DSM IV as authoritative, I guess you are stuck.

I view DSM 4 as just a guideline. If someone has mood instability or depressive systems, I have no problem putting 296.90 (mood d/o NOS) or 311 (depression NOS) on the billing form. There is not an exact correspondence between ICD-9 codes and DSM 4 diagnoses. How do you know that a borderline in crisis hasn't developed a comorbid axis one mood d/o?

My situation may be different from yours, however, because I am not a participant in any Mental health carve outs and BC/BS is the only major insurance co I am listed as a psychiatrist with; I am signed up as an internist with the rest.

If I am contractually bound to use DSM-4 I will. Otherwise I don't see any ethical dilemna in being flexible about dx.
 
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I view DSM 4 as just a guideline. If someone has mood instability or depressive systems, I have no problem putting 296.90 (mood d/o NOS) or 311 (depression NOS) on the billing form. There is not an exact correspondence between ICD-9 codes and DSM 4 diagnoses. How do you know that a borderline in crisis hasn't developed a comorbid axis one mood d/o?
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It varies per region & billing system...but again it addresses several issues that can be problems with the billing systems.

DSM IV truly is just a guideline. I believe it even says that in the book, but since I've had a tough day on inpatient I'm not going to find exactly where it said that. However when calling up the insurance company & trying to get a bed on an inpatient unit, they don't want to hear that.
NJ commitment laws specifically state the disorder has to be an Axis I. In the courtroom the judge does not want to hear that you liberally interpreted the DSM since its use is a legal standard when commitment court is around the corner.

But the reality is that several docs do slap on the Mood DO NOS or Depressive DO NOS.

You are also correct--that in a crisis center, where the psychiatrists only has a few hours tops & is pushed by the hospital quality standards to get the patient out ASAP, they're not going to be able to, with a strong degree of accuracy, rule out a comorbid mood DO.

However by day 3-5 on the inpatient, it can be ruled out with some degree of reasonable certainty. Unfortunately by that day, if you remove the Axis I DO (and let's assume for argument's sake that there is no Axis I DO), should that happen, the insurance company will not reimburse the hospital. This can be a pretty strong hit, especially since this applies to several patients at least at the unit I worked at (and from what I hear several others from friends on mine in other places).

It may also be different for you because you said you were signed up as an "internist". I had to do a presentation to the IM doctors at the hospital on having them screen their patients for mental illness & get paid for it. The new standard is forfor the primary care docs to detect mental illness & treat or refer. Several PCPs don't do this because of lack of knowledge on billing for mental illness.

When doing research for this topic, I found out that PCPs can often times bill based on sx. That's not an ability I had when I worked on inpatient psychiatry. As for the Axis IIs, our system was able to get paid for that, but only on outpatient & treatment couldn't be done by a psychiatrist. It had to be done by a non-psychiatric therapist. Again, inpatient--no reimbursement for an Axis I DO. This in turn often times lead to Borderline patients who showed up to the crisis center having done something dangerous being incorrectly diagnosed as depressed. Whenever I saw a patient who had a Depression dx who was recently discharged from inpatient & referred to outpatient, I didn't believe it until I screened them for it to rule out an Axis II.
 
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whopper said:
It varies per region & billing system...but again it addresses several issues that can be problems with the billing systems.

DSM IV truly is just a guideline. I believe it even says that in the book, but since I've had a tough day on inpatient I'm not going to find exactly where it said that. However when calling up the insurance company & trying to get a bed on an inpatient unit, they don't want to hear that.
NJ commitment laws specifically state the disorder has to be an Axis I. In the courtroom the judge does not want to hear that you liberally interpreted the DSM since its use is a legal standard when commitment court is around the corner.

But the reality is that several docs do slap on the Mood DO NOS or Depressive DO NOS.

You are also correct--that in a crisis center, where the psychiatrists only has a few hours tops & is pushed by the hospital quality standards to get the patient out ASAP, they're not going to be able to, with a strong degree of accuracy, rule out a comorbid mood DO.

However by day 3-5 on the inpatient, it can be ruled out with some degree of reasonable certainty. Unfortunately by that day, if you remove the Axis I DO (and let's assume for argument's sake that there is no Axis I DO), should that happen, the insurance company will not reimburse the hospital. This can be a pretty strong hit, especially since this applies to several patients at least at the unit I worked at (and from what I hear several others from friends on mine in other places).

It may also be different for you because you said you were signed up as an "internist". I had to do a presentation to the IM doctors at the hospital on having them screen their patients for mental illness & get paid for it. The new standard is forfor the primary care docs to detect mental illness & treat or refer. Several PCPs don't do this because of lack of knowledge on billing for mental illness.

When doing research for this topic, I found out that PCPs can often times bill based on sx. That's not an ability I had when I worked on inpatient psychiatry. As for the Axis IIs, our system was able to get paid for that, but only on outpatient & treatment couldn't be done by a psychiatrist. It had to be done by a non-psychiatric therapist. Again, inpatient--no reimbursement for an Axis I DO. This in turn often times lead to Borderline patients who showed up to the crisis center having done something dangerous being incorrectly diagnosed as depressed. Whenever I saw a patient who had a Depression dx who was recently discharged from inpatient & referred to outpatient, I didn't believe it until I screened them for it to rule out an Axis II.
Click to expand...

I agree with needing to strictly adhere to DSM 4 in court situations, since this is required by most committment laws.
In the clinical trials I help to run, I strictly adhere to DSM 4.

As far as inpt psych hospitalizations, unless it is a borderline you have been following as an outpt for a while, there is usually some doubt as to if there is a comorbid axis 1 dx. I haven't met too many pure borderlines. There usually is some element of PTSD or mood d/o present- in my opinion, which could be wrong. It sounds like we have different views of the borderline dx.

I am listed as "internal medicine, not intending to practice primary care" by most insurance companies (primary care docs have requirements about vaccines, etc). I haven't had any probs billing when I cover the local inpt psych unit, though most of those pts are medicare, medicaid or bc/bs. In my outpt practice, I haven't had any problems billing for addiction tx (suboxone).
 
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An article in the AMA News today noted that 10 of the 13 authors who published the original Lancet article in 1998 regarding the links between Autism and vaccination have retracted their original interpretation that their data indicated a causal link between MMR and autism. The lead author, Dr. Wakefield, is also being investigated for allegations of misconduct about this research. Interesting...😎
 
"Dear Abby" is not a healthcare professional.

autism is often considered a mental health disorder because it affects behavior, cognitive ability and social skills. However, it is genetically predetermined -- biologically based.
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Ahem, so if a disorder has a genetic & biological basis, its not a mental health disorder? OK, I guess Bipolar, Depression, Schizophrenia among pretty much most of the billable DSM Axis I disorders are not mental health disorders then, they're neurological disorders.

Dear Abby is a lady who happened to be a successful columnist by giving lay-person advice. She is by no means a professional. She's one of the reasons why as much as I hate Dr. Phil (and let's not forget he had his liscence removed from him for unethical professional conduct), I at least think he's better than most of the lot out there because at least he has a Ph.D. in his area. Dear Abby is no more qualified to give advice than Yenta from Fiddler on the Roof.
 
whopper said:
"Dear Abby" is not a healthcare professional.



Ahem, so if a disorder has a genetic & biological basis, its not a mental health disorder? OK, I guess Bipolar, Depression, Schizophrenia among pretty much most of the billable DSM Axis I disorders are not mental health disorders then, they're neurological disorders.

Dear Abby is a lady who happened to be a successful columnist by giving lay-person advice. She is by no means a professional. She's one of the reasons why as much as I hate Dr. Phil (and let's not forget he had his liscence removed from him for unethical professional conduct), I at least think he's better than most of the lot out there because at least he has a Ph.D. in his area. Dear Abby is no more qualified to give advice than Yenta from Fiddler on the Roof.
Click to expand...

I disagree. Yenta is much more qualified.
 
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