major depressive disorder vs adjustment disorder

[futuredo32]

I'm looking for some clarification on diagnosing adjustment disorder. I've worked with two different psychiatrists and they both had different opinions. On each rotation, I've seen patients with similar histories/symptoms and the psychiatrist each saw the diagnosis differently.

Here's the scenario- A patient has a history of major depressive disorder and was treated in the past for depression. We are now seeing the patient for a suicide attempt after a recent stressful event (relationship problem). The patient currently meets the criteria for major depressive disorder. Psychiatrist A diagnosed the patient as follows: Axis 1a: major depressive disorder recurrent, Axis 1b: rule out adjustment disorder with mixed disturbance of emotion and conduct. Psychiatrist B just used the Axis 1a diagnosis of major depressive disorder recurrent and stated that it didn't fit the criteria for an adjustment disorder because the symptoms better fit major depressive disorder.

I'm doing an audition rotation soon and I'd like to present my patients thoroughly and accurately to the attendings and I'm pretty confused about the correct and complete Axis I diagnosis for a patient like the one I have described. I'd appreciate any opinions about how this patient should be diagnosed. Thanks.

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[BabyPsychDoc]

You will frequently run into similar situations. IMHO, any psych disease classification is relative and incomplete, and subject to interpretation. In real life, the main question is, "How should I manage this patient?". Whatever the precise phrasing of the diagnosis, it is not going to affect management of the patient with a recent suicide attempt on the background of h/o MDD.

With regard to your audition rotation, show off your wide knowledge of DSM-IV and your flexibility in interpreting it: state that B is a possibility though A cannot be ruled out. You are not expected to be an expert diagnostician as a MS-IV - just an inquisitive, bright person (which it sounds like you are )

Just my 2 cents.

 

[Faebinder]

Insurance will not pay for adjustment disorder but they will pay for major depression recurrent.

Hence the problem and the underdiagnosis of adjustment disorder by many psychiatrists.

 

[TheWowEffect]

While I cannot comment on this specific case, as more details are needed, it is not uncommon for two psychiatrists to differ on diagnosis. There might be a theoretical bias, "insurance bias", knowledge gap or whatever.

It would help you more if you are able to give an exhaustive differential diagnosis when presenting cases, rather than coming up with a specific diagnosis. Attendings will ask you for a working diagnosis though and you can give the one you most strongly feel is the right one; with reasons of course.

 

[BabyPsychDoc]

Insurance will not pay for adjustment disorder but they will pay for major depression recurrent.

Hence the problem and the underdiagnosis of adjustment disorder by many psychiatrists.

Damn! I did not know that. Thanks.

 

[whopper]

The problem with 2 psychiatrists offering differing opinions comes down often to these factors--

1) Billing. The 2 psychiatrists may agree on the "REAL" diagnosis, but it may not be billable. One may stick to his/her guns & keep down the nonbillable dx. The other may fudge.

2) Availability of services: Similar problem. Some diagnosis can get services others can't. For example if you're a psychiatrist in the crisis center & someone comes in who cut their wrists & is a borderline PD patient, are you going to discharge that patient after only having the oppurtunity to observe the patient for a few hours tops? Most wouldn't. So they put down the diagnosis Depressive DO NOS, even if the patient is denying depression.

3) The 2 psychiatrists may have been given more or less data depending on what the patient revealed & what collateral sources revealed

4) The clinical quality of the 2 psychiatrists. Some try to take a very insightful look, others are just trying to get out of there ASAP to get their work done.

#'s 1 & 2 show some of the things in the system that need some fixing. The current billing system leads to several situations where patients need help but there's no billing code that fits them.

 

[erg923]

Although one can be formally diagnosed, and the other can be a rule-out, both MDD and Adjustment DO with depressive features can NOT both be diagnosed simultaneously. The DSM clearly states that if another Axis I condition accounts for the mood disturbance, Adjustment Disorder is trumped. This is because Adjustment DO with depressive features is used to explain the mood distrurbance only when another Axis I Disorder can not better account for the disturbance.

If a individual qualifies for MMD but there are identifiable psychosocial stressors that may have contributed to the clincial picture/depression, these events can always be mentioned in Axis IV. I am not saying this is the literal truth, but this is how it is to be done according to the DSM-IV-TR.

 

[futuredo32]

Thanks so much to all of you who commented. My audition rotation is a few months away and I'm already pretty nervous.

It's really sad that insurance companies will cover one diagnosis and not cover another. If a patient needs treatment, a patient needs treatment. *end of mini-rant*

 

[Therapist4Chnge]

This is because Adjustment DO with depressive features is used to explain the mood distrurbance only when another Axis I Disorder can not better account for the disturbance.

That's the important distinction.....though because of the insurance coverage, good luck actually seeing it anywhere other than maybe a college counseling center and/or cash pay practice.

 

[Hurricane]

That's the important distinction.....though because of the insurance coverage, good luck actually seeing it anywhere other than maybe a college counseling center and/or cash pay practice.

We diagnosed adjustment disorder on consults all the time. I have no idea what was going on with the billing, though, other than the fact I was required to fill out all these annoying cards...

 

[Anasazi23]

We diagnosed it all the time in the clinic also. What we're actually referring to in many instances is that an adjustment disorder is not justification for an inpatient admission.

 

[Therapist4Chnge]

We diagnosed it all the time in the clinic also. What we're actually referring to in many instances is that an adjustment disorder is not justification for an inpatient admission.

Ahh, okay. Yeah...I don't think anywhere would remotely consider inpatient for Adj Disorder.

 

[OldPsychDoc]

Ahh, okay. Yeah...I don't think anywhere would remotely consider inpatient for Adj Disorder.

I don't know--I'm pretty sure we've admitted people for crisis management and stabilization who were unable to contract for safety following a severe loss (spouse, child), though they had no past history of MDEs and less than 2 weeks of neurovegetative sx.

 

[BabyPsychDoc]

Ahh, okay. Yeah...I don't think anywhere would remotely consider inpatient for Adj Disorder.

It depends on the severity of the Adj Disorder.

 

[pingouin]

I don't know--I'm pretty sure we've admitted people for crisis management and stabilization who were unable to contract for safety following a severe loss (spouse, child), though they had no past history of MDEs and less than 2 weeks of neurovegetative sx.

I used to be a managed care case manager and yes, we would authorize an admission for something like this every once in a while. It was pretty rare, and we certainly didn't authorize many days for it, but if the criteria were met and the safety issue was there.. we did it.

 

[OldPsychDoc]

I used to be a managed care case manager and yes, we would authorize an admission for something like this every once in a while. It was pretty rare, and we certainly didn't authorize many days for it, but if the criteria were met and the safety issue was there.. we did it.

I wish it was so cut & dried...
Usually it's hx of MDD, severe, recurrent, now showing sx of MDE in context of 4 week cocaine & alcohol binge, termination of relationship, loss of job, and ongoing underlying primitive coping skills.... <sigh>

 

[Faebinder]

I wish it was so cut & dried...
Usually it's hx of MDD, severe, recurrent, now showing sx of MDE in context of 4 week cocaine & alcohol binge, termination of relationship, loss of job, and ongoing underlying primitive coping skills.... <sigh>

add to that opiate in their urine yet claiming they have chronic back pain and their PMD prescribes them lortabs for it.

 

[Anasazi23]

Ahh, okay. Yeah...I don't think anywhere would remotely consider inpatient for Adj Disorder.

I think we see adjustment disorder admits frequently. Though they're usually piggy-backed on a pervasive personality disorder. i.e. think of a borderline type with multiple parasuicidal attempts whose boyfriend broke up with her and she's hysterical over it.

 

[Therapist4Chnge]

I think we see adjustment disorder admits frequently. Though they're usually piggy-backed on a pervasive personality disorder. i.e. think of a borderline type with multiple parasuicidal attempts whose boyfriend broke up with her and she's hysterical over it.

I was going to include this, as although the prevalence rate for Adj Disorder is pretty high, the more severe presentations often seem to be the smoke for the fire.

 

[BabyPsychDoc]

I think we see adjustment disorder admits frequently. Though they're usually piggy-backed on a pervasive personality disorder. i.e. think of a borderline type with multiple parasuicidal attempts whose boyfriend broke up with her and she's hysterical over it.

How frequently do you actually admit borderline personality disorders with multiple parasuicidal attempts? When I did my ER psych, we would discharge most of those. We accepted the risk that they might end up dead (take too many tablets, call for help too late, etc), but if they did not have a co-morbid Axis I diagnosis, there was nothing to be gained by the admission. I only remember one case (young and bright borderline woman that was failing in her therapeutic community and was getting depressed over the fact) that we actually had to admit (and commit), but as I said she was severely depressed at the time (plus her last parasuicide attempt was about 10years previously, so when she arrived at the ER unconscious after carefully planned paracetamol+EtOH OD a few days earlier, that was to be taken seriously).

having said all that, I am currently practising in a different country, in a different system, so I am really interested if this issue is handled differently in the US.

 

[Anasazi23]

How frequently do you actually admit borderline personality disorders with multiple parasuicidal attempts? .

It entirely depends on the hospital, whether or not that hospital has a residency program, whether or not the attending of said resident of said hospital has been sued prior, and most importantly, the bed census.

 

[TheWowEffect]

It entirely depends on the hospital, whether or not that hospital has a residency program, whether or not the attending of said resident of said hospital has been sued prior, and most importantly, the bed census.

It may also depend on the resident's level of training

 

[BabyPsychDoc]

Gotcha.

 

[michaelrack]

A senior attending at the local univ was big on DSM 4. When lecturing to students/residents, he used to stress the need to differentiate MDD from adj d/o, and that adjustment d/o was not treated with antidepressants, that it was treated with supportive therapy and perhaps a short-term benzo.

When I was covering his private patients as a junior attending while he was on vacation, I came across one of his charts in which antidepressants were being used to treat a supposed adjustment disorder.

In the real world a patient's diagnosis has more to do with reimbursement issues or the desire to avoid a stigmatizing diagnosis than precise DSM 4 criteria. A lot of times psychotropics are used to treat symptoms clusters rather than a diagnosis.

To the OP: I agree with BabyPsychDoc's advice: be prepared to show your knowledge of DSM 4 as well as be able to generate/justify a differential dx. Don't be surprised, though, if the "correct" diagnosis is not the one that ends up in the chart (thought it often will).

 

[whopper]

I'm wondering if fudging on billing is ever brought up as an ethical & legal issue.

In the strictest sense it can be considered fraudulent activity on the part of doctors. This isn't just against psychiatrists but against all fields of medicine. In all fields, I've seen cases where doctors were ethically required to give their patient service that would've required a lot of time, but because of the billing system, they could not bill for it. So then they'd fudge & write it down as something it wasn't--e.g. an ear ache.

It also brings up problems that need to be directed also against managed care. They give us a system that does not allow us to bill for several situations that needs urgent care. E.g. Munchausen's by proxy is not a billable diagnosis, but it could've taken several hours if not days of investigation to discover that diagnosis. Correctly diagnosing that disorder could also potentially be life saving for the child. Why won't the managed care companies put that down as a billable disorder?

Other diagnosis I've seen that aren't billable but required urgent care--Borderline PD (especially when the person is parasuicidal), Schizophreniform DO, Brief Psychotic DO, Malingering, & Factitious DO.

The latter 2 diagnosis require a doctor see the patient for at least a few days before other diagnosi in the differential can be ruled out. So by the time you figure out that the guy is malingering or faking sx for attention, you've now had a patient in inpatient for about 3-4 days, and now you got nothing to billable & the institution will hold you out of favor for not fudging & putting down some other disorder such as Depressive DO NOS. When you put that disorder down, you're now creating the first step in the revolving door system. Now whenever this malingerer or factitious patient comes into an ER, there'll be a written record of a "real" psyche disorder and that'll make that ER doc or crisis psychiatrist more likely to put them into the revolving system.

As for Schizophreniform DO or Brief Psychotic DO, some of you will argue that we could just write down Psychosis NOS. Well according to the DSM criteria for Psychosis NOS, it can't meet the diagnostic criteria of another disorder--so technically, by putting that DO down, you're violating the criteria for Psychosis NOS--again in the strictest sense this is fraudulent.

 

[michaelrack]

Whopper, you bring up some good points.

However, not all insurance companies require you to use Dsm 4 for billing diagnosis (though it is often required for admission criteria), many allow you to bill using ICD 9, which does not have precise diagnostic criteria. Dsm 4 is probably more important for inpt than outpt situations. Does anyone know what the policy is for Medicare/medicaid??

I don't like the diagnosis of schizophreniform disorder. It's not a distinct biological entity. I think DSM 5 should get rid of it and add a modifier to the schizophrenia diagnosis for situations in which a patient has had symptoms for less than 6 months and the diagnosis is unclear.

 

[BabyPsychDoc]

Interesting. I have always thought it is nice DSM-IV has "schizophreniform disorder" as a separate diagnostic entity. ICD-10 does not allow such a luxury, so if the psychosis lasts for >1 month it is schizophrenia (<1 month it is acute psychotic episode, like in DSM-IV). MyI understand this is due to the fact that schizophrenia used to be widely overdiagnosed by American psychiatrists in 1960s-1970s, so the "interim" diagnosis was introduced into DSM-IV to avoid the issue (kind of).

I had a patient who had psychosis lasting for 5 weeks in the acute form, and then it took another 4 months for her to get back to normal life completely. Now she has been discharged from any follow up by psych services since Dec 2006, well and asymptomatic, off any meds. She still has to carry the stigma of "schizophrenia" with her. Now, I realize she may well relapse some time later. But, until then (if it ever happens), I think it would be nice for her to have a "nicer" diagnosis to clutch on.

I wonder if there are any insurance implications (ie, would your life/health/disability insurance premiums be less affected if you are diagnosed with schizophreniform disorder as opposed to schizophrenia? In the UK, they just ask you about "serious mental illness", which pretty much encompasses everything from PND to catatonic schizophrenia )

 

[michaelrack]

I wonder if there are any insurance implications (ie, would your life/health/disability insurance premiums be less affected if you are diagnosed with schizophreniform disorder as opposed to schizophrenia? In the UK, they just ask you about "serious mental illness", which pretty much encompasses everything from PND to catatonic schizophrenia )

I think in the US both schizophrenia and schizophreniform diagnoses would make it hard to get an individual insurance policy.

 

[YOOOUK09]

A good NYTimes article about this topic:

http://www.nytimes.com/2008/09/16/h...6b&ei=5124&partner=permalink&exprod=permalink