CMH and inappropriate dxes?

Discussion in 'Psychiatry' started by ProZackMI, Dec 7, 2005.

  1. ProZackMI

    ProZackMI Psychiatrist/Attorney
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    Anyone else out there see misdiagnoses from MSWs, PhDs, and MDs/DOs working out of CMH or similar agencies? I frequently see Bipolar I or II diagnosed, but without meeting the DSM criteria. I also see schizoaffective D/O, MDD, ADD/ADHD, and BPD frequently diagnosed without meeting the DSM criteria.

    It appears that many of these diagnoses are the result of the practitioner's reliance on the patient's subjective description of his/her sxs and/or reliance on the patient's hx rather than objective observations, testing, or actual clinical diagnosis using DSM standards.

    It might be the limited time and resources of the CMH practitioners, but I find this trend somewhat disturbing and inappropriate. I have at least 10 patients who started tx in CMH and were incorrectly diagnosed with Bipolar Affective D/O, a few of whom were Rx'd Lithium or Depakote. The dx was inappropriate and based on subjective sxs rather than objective observations and DSM criteria.

    Anyone else experience this trend?

    Thanks,
    Zack
     
  2. OldPsychDoc

    OldPsychDoc Senior Curmudgeon
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    Part of the problem is that many CMH systems require a certain severity of diagnosis for eligibility for services--i.e. you can't get someone a case manager if they're just a 311, or even a 296.22. You need them to be bipolar, psychotically depressed, or schizophrenic. There's often some pressure to inflate the diagnosis in order to get the patient treatment.
     
  3. ProZackMI

    ProZackMI Psychiatrist/Attorney
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    That's just...wrong though. Don't you think?
     
  4. littlepurplepil

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    I saw an eleven year old in the ER who carried Dx of Bipolar D/O and Schizophrenia....taking both Zoloft and Abilify for at least one year. Seemed a bit extreme to me; although possible, how plausible would it be to see a disorganized eleven year old with comorbid mood disorders?
     
  5. OldPsychDoc

    OldPsychDoc Senior Curmudgeon
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    There are a LOT of things that are wrong out there...
    I would not "upgrade" a diagnosis to get someone disability payments, but there are times when you might need to "spin" or "package" diagnostic criteria to get a patient the appropriate treatment--especially when the unique individual doesn't fit in the coder's neat little boxes.
     
  6. pingouin

    pingouin just chillin'
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    Very true at the CMHC where I used to work- we had a "long list" of about 13 diagnoses that qualified for state DMH funding, and a "short list" of about 7 in times when budget was really tight. Luckily we had some grant funds for therapy, but that didn't cover medication management for the uninsured.

    To comment on the OP's concerns- I agree, and I wonder if it's more pervase in the private sector than is recognized. I did a stint in the wonderful world of managed behavioral healthcare, and the company I was with was tracking the diagnosis of bipolar I disorder in children and adolescents, as reported on MD/DO outpatient treatment plans and inpatient admission records. In '04, they reported something in the ballpark of a 275% increase over a two year period, which was apparently comparable with other MBHOs doing similar studies. Although certainly increased awareness of childhood bipolar has increased diagnosis, it seemed unlikely that the jump would be that big. The suspicion was that upcoding was being done from ADHD/ODD/Conduct Disorder as the latter two were non-covered diagnoses for inpatient care.

    You can only imagine how the intake counselors reacted when we started asking them to justify their diagnoses based on the DSM criteria (whether they were giving them provisionally or the psychiatrist had informed them)... you're absolutely right- not nearly enough adherence to the criteria- especially in the area of length of symptoms.
     
  7. Poety

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    Ok, my question regarding changing or "upgrading" the diagnosis in someone so they can get benefit coverage is this: What about the ramifications of carrying this diagnosis for the rest of your life?

    We all know how being diagnosed with a mental illness can have negative effects such as the person using maladaptive behaviors and blaming it on their "illness" or worse yet, someone who wants to shed their diagnosis but can't because its so severe. I mean a child diagnosed with bipolar d/o may never actually mature into whoever they would have without the diagnosis since they'd be funneled into the system so early with treatment and meds -
    I should also state that I'm one of the people that would tend to err on the safer side of med administration to children in the sense that I would want to avoid it at all costs - I've had No experience with child psych yet but my instinct tells me that if we mess with the chemistry too early - it DOES effect the outcome - and we don't know enough about the brain to do this safely - ack if I get flamed, please understand I'm coming from a naive standpoint here ok?

    OPD, Zack, and the above poster - do you have any thoughts on this?
     
  8. ProZackMI

    ProZackMI Psychiatrist/Attorney
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    I don't treat kids under 13, usually, but when I do, I stay clear of prescribing meds. Why? First, I don't believe that most childhood behavioural problems are endogenous, and therefore, would not require pharmacological intervention. There are some that do, but most often, in my practice, I see kids with ODD/Conduct D/O, mild to moderate ADD/ADHD, and Adjustment D/O. Rarely do a I see a true bipolar I or II in a kid under 13/14; it does happen, but it's rare.

    I try to avoid prescribing more than one psychotropic to an adolescent (~13 to 23). Sometimes it is necessary, especially when there's potential self danger or danger to others, but for the most part, I try to avoid prescribing to kids and adolescents.

    It bothers me when I see kids who are 3-10 different psychotropics. What's even more disturbing is when these meds were prescribed by an internist, pediatrician, family practitioner....or <shudder> NP/PA (no offense, Dr. Poetry!). It can be very disturbing to see kids overmedicated like that.

    Enough of my rant...
     
  9. Poety

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    Oh I wasn't an NP or PA I was a plain old nursey nurse :) Thanks for the response! I currently have to agree with your views on treating young children - its gotta be tough. Perhaps I won't like child at all since I really think a lot of it is the parents and not the kids
     
  10. pingouin

    pingouin just chillin'
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    Poety,
    I hear you on the "marked for life" issue. For my company, I'm sure that cost was a factor in making us bear down on justification of diagnosis- ie, if it's really conduct DO-which they didn't have to pay for- but the facility is trying to say that the "impulsivity" or "risk-taking behavior" was part of a "manic episode"- which they do have to pay for. But for we non-bean counters, it's the difference in arranging appropriate treatment- if it is true bipolar, med management would be prioritized, with supplemental psychotherapy after stabilization. But for a behavior problem, behavioral mod (or perhaps a referral to juvenile detention) would be prioritized; med management might be used, but not in all cases.

    I've also seen clinicians underdiagnose, which can also limit access to benefits- though less harmful in the long run, probably. (And in this instance, I'm largely omitting psychiatrists and referring to a few psychologists and mostly masters-level therapists.) For example, a therapist was angry no additional sessions were authorized for a client she'd seen for over a year. She didn't want to stigmatize or label, so she'd diagnosed an adjustment disorder and never changed it. By their definitions, adjustment disorders don't even last a year, so we had a little chat about how if the client was still symptomatic, perhaps she needed to review the accuracy of the diagnosis based on current symptoms and resubmit her treatment plan.

    I always loved doing an intake on a patient at an academic facility- it was usually a resident who called in the clinical, very thorough, concise, accurate. The worst was the facility (actually a rural academic free-standing psych hospital) which didn't have an intake staff except for the phone operators and perhaps an LPN. :scared: Most intake departments in my area are staffed by MSWs/MAs, some licensed, some not, some excellent assessors, some... not.

    Regarding the meds issue, I cheer on psychiatrists who are cautious with prescribing, especially to kids. I'm with you- a firm believer that although there are some kids who are truly ill, there are many more who need more structure and positive parenting instead of pills. I'm a big proponent of trying behavioral mod first, and going to meds as a last resort; however that doesn't offer the quick fix that the parents (or just as often, the schools...) want. I have occasionally told parents "let's start with least-invasive measure, and work our way up if it's needed." Sometimes it works, sometimes not so much. A few parents are dead-set on medication, and will doctor-shop until they get one who will do it. I once had to tell a mother that per our system, she had taken her child to every child psychiatrist on our panel within a 50 mile radius of her home and I had no additional referrals to give her.

    On the adult end, there are a few psychiatrists I specifically refer to because they prescribe minimally, and frequently do med washes when they get a new patient with multiple meds. This goes along with my "enough but not too much" philosophy.
     
  11. Poety

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    Wow thanks for that response JLW! It really is interesting to read about the how why and when of actual prescribing and diagnosing - especially when it really can have a huge effect (good or bad) on someones life. I'm glad to hear that the two who have responded are actually a bit on the more conservative side. I actually interviewed at a place, and I don't know if she was tired, or didn't realize what she said but she statedt hat they "most commonly medicate children" :eek:
     

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