The Top Five Psychiatry Events of 2013

Dec 13, 2013

Five key events in 2013 will leave a longlasting mark on psychiatry. Here: a look at the impact that CPT coding, DSM-5, sunshine laws, a shrinking market for “shrinks,” and I-STOP are likely to have on our field.

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CPT coding and the re-medicalization of psychiatry

Starting January 1, 2013, psychiatrists adopted the E&M (evaluation and management) billing codes used by medical colleagues. These billing codes affect more than money and mean more than promises of “parity” with other medical specialties. Learning coding is confusing and time-consuming-but CPT codes redirect our “gaze” and change the way psychiatrists think. This may be one of many steps toward ending the supposedly “separate but equal” categories of “mental illness” and “medical illness.”

Back in 1977, then-president of the APA Mel Sabshin, MD, urged psychiatrists to return to their medical roots-roots that were frayed by psychoanalysts who deemed medical training unnecessary and accepted “lay analysis” instead. Change takes time, however. The power and prestige of psychoanalysis faded slowly but surely, but still leaves its legacy. In 2013, the AMA elected a psychiatrist, Jeremy Lazarus, MD, as its president.

APA and AMA presidential pronouncements aside, the substance of CPT coding shifts the attention of psychiatrists. Higher CPT codes include the same “review of systems” as medical examinations. They require notation of basic neurological observations (gait, station, tremor, muscle strength, pupil size, orientation, memory tests, etc), plus vital signs, weight, girth, and possible comments about skin, hair, respiration, etc. The standard mental status findings (speech patterns, relatedness, affect, unusual perceptions, etc) remain. Coding rules let us choose among 9 items from a preset menu. In short, psychiatry is treated like ophthalmology, another “single-system specialty,” rather than psychology.

Many psychiatrists already perform these functions. When we prescribe lamotrigine, for example, we inspect skin for rashes and signs of Stevens-Johnson syndrome. Lithium prescribers check for tremor, ataxia, and acne, as well as lithium and lymphocyte levels and thyroid and kidney function. The Abnormal Involuntary Movement Scale is subspecialists or not, we instinctively look for track marks or new tattoos. The examples are endless-but now we organize our impromptu physical examinations better. As for checking drug-drug interactions or possible pregnancies-how could we not?

To qualify for higher payments, we make more observations and more notations (provided that such detail is essential to our patient’s problems at that visit). Conferring with relevant medical specialists or generalists-not just with therapists- also boosts the code. We know that money motivates most people- and that “contingency management” (cash rewards) even motivates previously untreatable substance users. We can expect higher-paying CPT codes to motivate MDs and DOs to change their behavior.

That’s only one-third of the story. These CPT codes force psychiatrists to assess the specifics of their patients’ subjective complaints, evaluate objective signs and symptoms systematically, and consider differential diagnoses (which include “medical mimics”). Psychiatrists are no longer passive listeners; they are active assessors.

Documenting CPT codes reminds psychiatrists to choose treatment modalities after the evaluation. If psychotherapy is added, it earns an “add-on code” and gets extra reimbursement as a “procedure.” Psychotherapy is not the automatic outcome of every psychiatric visit. Psychopharmacology, transcranial magnetic stimulation, electroconvulsive therapy, breathing techniques, dietary changes and (in theory) even psychosurgery can be prescribed. Referrals to specialists or requests for tests may be ordered before proceeding.

The bottom line: psychotherapy is just one of many arrows in the psychiatrist’s quiver. Before shooting an arrow, we identify the target (symptoms), and then take aim.

DSM-5

DSM carries greater significance to nonpsychiatrists. No doubt it will inspire dissertations on the history of psychiatry and the philosophy of science. It will fuel anti-psychiatrists who view DSM as a political (or maybe economic) tool rather than a scientific statement. Public disputes between the heads of the NIMH and DSM authors augmented uncertainty about the scientific validity of DSM-5-but that is nothing new.

The good news about DSM-5: its publication invites greater public and professional awareness of the “4 A’s” of adult psychiatry: Alzheimer’s; ADHD; addiction; and autism spectrum disorder (ASD)-formerly known as Asperger’s. As the onetime “youth culture” approaches geriatric status, concerns about the continuum (or lack thereof) between “minor and major cognitive disorders” increase. (For instance, are senior moments the start of senility?) By listing Alzheimer’s as one of a dozen different “major cognitive disorders,” DSM-5 reminds us that “all is not Alzheimer’s” and that distinctions apply.

Autism and Asperger’s got extra press when outspoken advocates opposed plans to lump them together into a spectrum disorder. By now, an Asperger’s diagnosis carries a certain cache. No wonder many were disappointed by Asperger’s official disappearance. Autism, on the other hand, is seriously disabling but sometimes responds to treatment or even remits-to a degree. Although more and more genetic and epigenetic links to ASD are being identified, the syndrome remains enigmatic- even if its ranks expand. Few readers now remember when autism was blamed on “refrigerator mothers”- but those who are old enough to recall those days are probably as impressed by DSM-5’s progress as I-even if it remains imperfect.

ADHD got a little boost-not a big boost-when DSM-5 raised the age limit. Stimulants used to treat ADHD take us to another realm: namely, the risks of misuse, diversion, and doctor shopping.

Addictions and alcoholism still stir debate, partly because they hover between moral and medical. However, DSM-5 offers a ray of hope, since pundits predict that persons with substance use disorders stand to benefit most from planned changes in the Affordable Care Act.

2013 sunshine laws mark big pharma’s sundowning

In 2013, Senator Grassley’s (R, Iowa) wish was granted: pharma gifts to physicians (eg, food, books, or cold hard cash) must be posted, for all the world to see. When he first revealed that 1 of 3 psychiatrists was receiving honoraria from pharma, the situation sounded dire. Since then, pharma cut back displays and free food at APA conferences and limits research grants, yet pharma ads still appear in APA print and electronic publications-as they do in most other medical publications and Web sites. Without subsidized conferences, individual practitioners have fewer opportunities to sit beside fellow psychiatrists in informal settings and learn about standards of practice in other locales. Less peer exchange is a big loss.

And fewer new CNS meds are in the pharma pipeline. This is a potential loss for patients. The issue is being assessed by the APA’s 2013 president, Jeffrey Lieberman, MD. Damned if you do, damned if you don’t.

The Great Recession of 2007 imposed cost-consciousness on all fronts. Generics now outsell branded meds, rather than the other way around.

More patients expect practitioners to know as much about cost-containment as about pharmacokinetics. As a corollary, adverse effects of newer and costlier meds, such as atypical antipsychotics, get more publicity, while the generations that witnessed “thorazine shuffles” and disfiguring dystonias from “typicals” are retiring or remaining silent. However, hallucinogens made news in 2013. After going underground for half a century, research that was shelved shortly before the Summer of Love (1967) is being reconsidered and recycled. Preliminary results are promising.

Illinois Senate defeats psychologists’ prescriptive privileges

DISCLOSURE: I was born, reared, and educated in Illinois, and so I overvalue this event.

Illinois was a battleground for “prescriptive privileges” for years. The near pass-but eventual defeat- of this 2013 bill shines a spotlight on the “scope of practice” of non– medically trained psychologists. By implication, lobbying efforts demean the demands of medical school, neglect the many layers of “psychiatric medicine,” and reduce psychiatric practice to “prescriptive privileges” and nothing more. The war waged (and won) in Illinois simultaneously directs our attention to psychotherapy practices, of both psychiatrists and psychologists (and other mental health professionals).

On the surface, this bill questions the nature and necessity of medical training, both classroom and clinical, and asks how it informs differential diagnosis, choice of treatment, and knowledge of drug actions and interactions in healthy patients and in those with comorbid medical conditions. Beneath the surface, this push for psychologists’ prescriptive privileges makes us ask who’s doing psychotherapy, how, why, and when?

Specifically, who’s “minding the farm” while (some) psychologists jockey for “pharma” privileges? Did psychologists stop doing psychotherapy? A damning 2011 New York Times article implies that money alone shifts psychiatrists away from psychotherapy.1 Psychiatry journals report similar drops in psychotherapy provided by psychiatrists. Such shifts started well before 2011.

In 2012, Gottlieb2 cited a 2010 paper from the American Psychological Association in an article published in The New York Times Magazine. That psychologist-only organization reported a 30% drop in therapy visits over the past 11 years-for psychologists! Apparently, there is a shrinking market for “shrinks.” Yet the market for quick cures, pharma fixes, and herbal remedies expands.

Perhaps distressed persons seek less therapy because pharma treatments are faster, more effective, or more convenient. Clearly, pharmaonly treatment does not suffice for all patients, as almost all psychiatrists attest. Perhaps progress in psychopharmacology ameliorated more psychological woes than many are willing to admit. Maybe our patients do not need the same-or as many- treatments as they did before pharma advanced. Some patients say they do not have time for therapy. We live in a fast-food, fast-paced society, where the Internet offers instantaneous information. Should we be surprised that Americans expect fast-pharma solutions as well? I’m not. Perhaps psychotherapy is not sufficiently cutting edge to compete with life coaches, yoga retreats, herbal alternatives, or Oprah.

Rather than reflexively blaming managed care or bad reimbursements for plummeting psychotherapy utilization and rather than relying on economic determinist explanations exclusively, we need data on all societal shifts influencing changing treatment patterns. As for psychiatrists’ familiarity with therapy: there is a rumor going ’round that psychiatric residents are not trained in therapy. Au contraire. They are required to learn 5 different types of talk therapy to complete residency requirements.

New York State I-STOP

I-STOP (Internet System for Tracking Over-Prescribing) regulations went into effect in New York State in late August of 2013. To comply, prescribers must check the state database before prescribing controlled substances. Most anxiolytics (benzodiazepines), soporifics, and stimulants are subject to these regulations, as are opioid-based pain pills, testosterone, and some muscle relaxants.

One might think that the soaring death rates from prescription opioids fueled this law, yet it seems that the real impetus relates to overused/ overprescribed amphetamines, as detailed in The New York Times articles in 2012 and 2013.3,4 In other words, psychiatric meds are under scrutiny, by both the state and psychiatrists. Since a disproportionate percentage of psychiatrists practice in New York State, this bill has broader implications than it seems.

I-STOP stands for overprescribing, which says nothing about doctor shopping. The onus is on the prescriber, not the dispensing pharmacist or the duplicitous patient. I-STOP will force psychiatrists to distinguish between curative psychiatry; cosmetic (performance) psychiatry; and plain old double dipping, either for addiction or diversion-or for both. I expect it to raise questions about some patients’ motives and psychiatric prescribing patterns. For sure, it will increase awareness of addiction.

Disclosures:

Dr Packer is Assistant Clinical Professor of Psychiatry and Behavioral Sciences at the Albert Einstein College of Medicine, Bronx, NY. She is also in private practice in New York City. She reports no conflicts of interest concerning the subject matter of this article.

References:

1. Harris G. Talk doesn’t pay, so psychiatry turns instead to drug therapy. New York Times. March 5, 2011. http://www.nytimes.com/2011/03/06/health/
policy/06doctors.html?pagewanted=all. Accessed November 5, 2013.

2. Gottlieb L. What brand is your therapist? New York Times Magazine. November 23, 2012. http://www.nytimes.com/2012/11/25/magazine/
psychotherapys-image-problem-pushes-sometherapists-to-become-brands.html. Accessed November 5, 2013.

3. Schwarz A. Risky rise of the good-grade pill. New York Times. June 9, 2012. http://www.nytimes.com/2012/06/10/education/seeking-academicedge-
teenagers-abuse-stimulants.html. Accessed October 31, 2013.

4. Schwarz A. Drowned in a stream of prescriptions. New York Times. February 2, 2013. http://www.nytimes.com/2013/02/03/us/concerns-about-adhdpractices-and-amphetamine-addiction.html. Accessed October 31, 2013.

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