What do the words "primary psych disorder" mean?

[nancysinatra]

So patients cannot be involuntarily signed into our psych EC (or our inpatient unit) if their absolute only problem is drug intoxication. Same is true if their only problem is known to be antisocial personality d/o. Today I tried to dodge a consult in the ER which was for "agitation and paranoia" that was clearly due to drugs and nothing else. It did not seem like something you would call "primary psych."

However, substance abuse is in the DSM in a wide multitude of permutations. Primary psych or not, I would have no trouble labeling this patient with an Axis I disorder. The same is true for ASPD. Even malingering is a V code, I believe, and you could interpret it in such a way as to qualify as an antisocial trait and thus be a psychiatric symptom. Then there are smaller things like nicotine and caffeine dependence and jet lag. All these are in the DSM yet I doubt anyone would call them "primary psych" disorders. I bet almost no one would commit a patient to an inpatient unit just on the basis of nicotine dependence, for example.

So my question is, why are things like schizophrenia and depression considered "primary psychiatric" but many other things, including drug use, are not? At least not for the purposes of many consults, admissions and commitment laws. The distinction seems really arbitrary to me!

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[atsai3]

So patients cannot be involuntarily signed into our psych EC (or our inpatient unit) if their absolute only problem is drug intoxication. Same is true if their only problem is known to be antisocial personality d/o. Today I tried to dodge a consult in the ER which was for "agitation and paranoia" that was clearly due to drugs and nothing else. It did not seem like something you would call "primary psych."

However, substance abuse is in the DSM in a wide multitude of permutations. Primary psych or not, I would have no trouble labeling this patient with an Axis I disorder. The same is true for ASPD. Even malingering is a V code, I believe, and you could interpret it in such a way as to qualify as an antisocial trait and thus be a psychiatric symptom. Then there are smaller things like nicotine and caffeine dependence and jet lag. All these are in the DSM yet I doubt anyone would call them "primary psych" disorders. I bet almost no one would commit a patient to an inpatient unit just on the basis of nicotine dependence, for example.

So my question is, why are things like schizophrenia and depression considered "primary psychiatric" but many other things, including drug use, are not? At least not for the purposes of many consults, admissions and commitment laws. The distinction seems really arbitrary to me!

This largely has to do with reimbursement for the hospitalization. Some insurers, for example, will not reimburse for the hospitalization if the only diagnosis is borderline personality disorder or substance induced mood disorder -- there needs to also be a diagnosis of major depressive disorder as well.

Good luck dodging the consults. Psych routinely gets paged to see patients where the justification for our involvement is flimsy. For example, in many emergency departments, psych will get called to see patients who are being violent. But perhaps they should just be carted off to jail. Hospital policy attempts to balance false positives vs. false negatives. And with regards to some issues, the weight of history is not on the residents' side.

-AT.

 

[michaelrack]

.

So my question is, why are things like schizophrenia and depression considered "primary psychiatric" but many other things, including drug use, are not? !

Because "Psych Patients" are often paid for by the tax payers, and while tax payers may be willing to pay for hospitalization for a psychotic bipolar patient, they are less willing to pay for hospitalization/rehab for a psychotic crack head. (this grossly simplifies the situation, but this is how many of the general public think about the issue).

 

[nancysinatra]

Because "Psych Patients" are often paid for by the tax payers, and while tax payers may be willing to pay for hospitalization for a psychotic bipolar patient, they are less willing to pay for hospitalization/rehab for a psychotic crack head. (this grossly simplifies the situation, but this is how many of the general public think about the issue).

Well then, why isn't this line of thinking conveyed to residents from fields like IM, EM and surgery who want consults for patients whose problems are related to nothing more than malingering, antisocial behavior or drug use? Ultimately the costs of these consults or ER visits get passed on to the taxpayers as well. It's no different than providing such individuals with an inpatient psychiatric hospitalization. If the public doesn't think that the psychotic crackhead is deserving of an inpatient psychiatric stay complete with psychology groups and occupational therapy, do you think the public would approve of the psychotic crackhead getting yet another psychiatric consult at 2am just because some lazy medicine resident in the ER doesn't care to do a urine drug screen or read the last note from psychiatry on that same patient, or review the criteria for schizophrenia in order to bolster their case that "this patient is really really paranoid and has a psych history?"

How can we avoid this pattern?

I hope I live to see the day when psychiatry has more lab tests than medicine, and medicine becomes a diagnosis of exclusion and we can turf all our patients to them in the form of bogus consults!

 

[Doc Samson]

Two thoughts:

1) A "primary psych disorder" just means that it's not "secondary" to another underlying disturbance - so "garden variety" depression/mania/psychosis/anxiety rather than symptoms due to a medical condition or substances. Limitations on inpatient admissions/commitments are based on the thinking that if you remove the underlying cause (e.g. crack) the presenting symptom (e.g. agitation) will resolve in short order without complicated and costly psychiatric treatment. Not always the case, obviously.

2) Just because someone's symptoms are secondary to something else doesn't mean that: a) they don't need treatment, and b) we're not the best trained/equipped to provide that treatment. I spend almost my entire work week assessing and treating folks with neuropsychiatric symptoms secondary to something else (delirium, the effects of stroke, epilepsy, etc.).

 

[kugel]

I see the phrase "Not a primary psych disorder" most often used to imply one of three things:

1) "It's not my job." Someone else needs to deal with this. I'm too busy or too important to deal with this. Or else, that another part of the system (i.e. the drug/alcohol part of the healthcare system) should be dealing with this.

2) a pejorative. a euphemism or code so that means I can dismiss the problem or the patient. The same way that, "This is all just Axis II" is sometimes used to mean that the patient is exaggerating/lying or simply "I don't like him."

3) It's not billable. (and so, therefore, I'm not going to waste my time on it.)
By the way, this is often NOT true. A lot of MD's go around spouting untruths about what makes something "billable" for inpatient care.