to buy or not to buy, that is the question…

Posted on Friday 15 February 2013

    sitting quietly
       doing nothing.
          spring comes
    and the grass grows by itself…
Zen poem by Basho

Matsuo Basho (1644-1694)

We think about it more now than we used to, but it still hasn’t thoroughly sunk in – the USA is just a country in a world of many countries. And from a medical perspective, the real overarching organization is the WHO established by the United Nations. One of its functions is to maintain the The International Classification of Diseases [ICD]. The United States is treaty bound to use the ICD to report diseases to its public health database – vital for health policy decisions around the world. For obvious reasons, the ICD is also the standard used for other reporting – Medicare, Medicaid, third party carriers, CDC, etc.

The International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] is the official system used in the United States to classify and assign codes to health conditions and related information. The use of standardized codes improves consistency among physicians in recording patient symptoms and diagnoses.
The ICD-9-CM contains a list of alphanumeric codes which correspond to diagnoses and procedures recorded in conjunction with hospital care in the United States. For example, a patient with acute appendicitis will be assigned a code of 540. This code may be entered onto a patient’s electronic medical record and used for diagnostic, billing and reporting purposes. Related information also classified and codified in the system includes symptoms, patient complaints, causes of injury, and mental disorders.
The United States Department of Health & Human Services and the Centers for Medicare and Medicaid Services created ICD-9-CM as an extension of the Ninth Revision, International Classification of Diseases [ICD-9], which the World Health Organization [WHO] established to track mortality statistics across the world.

Of course, we have to be a bit special, so the official disease classification is the ICD-9-CM [The International Classification of Diseases, Ninth Revision, Clinical Modification] a subset for America. While there’s currently an ICD-10, the US version [ICD-10-CM] won’t be in use until 2015 if even then. Because the ICD-11 is in preparation, due out in 2015-2016, it’s possible we’ll just skip ahead to it. The only thing that matters to we mortals is that the ICD-10 and coming ICD-11 use a different coding scheme than the ICD-9 and ICD-9-CM, so all the codes are different even if the diagnoses have been kept the same. That’s the major reason that we haven’t made the changeover. Every computer system will need redoing, a massive and expensive task. These weighty matters are beyond my further elucidating powers [or patience], but I’m pretty sure I’ve got that part right.

The Diagnostic and Statistical Manual [DSM] is a creation of the American Psychiatric Association. It came to life in 1952 as a simple code-book with terse definitions [DSM] revised in 1968 [DSM-II]. The creation of the DSM-III in 1980 was something very different. It was written as a textbook with defined diagnostic criteria for each disorder. It was still a code-book and the codes were from the ICD, but it was treated as much more. It was adopted everywhere, or so it seemed. But what was official were the codes. The definitions were simply what the APA Task Force said they were.

Which brings us to now, with the DSM-IV [1994] as the widely used standard in mental health. The American Psychiatric Association is suggesting that we buy their DSM-5, due out in May this year. Well, it’s going to have the same diagnostic codes as the DSM-IV – the ICD-9-CM codes. And when they finally change-over to the ICD-10-CM or the ICD-11, the DSM-5 will have to change too. So the DSM-5 is the official code-book for the APA. But that has about the same meaning as Papa John’s Pizza is the official pizza of the super-bowl [which is no meaning at all]. Eating Dominos is allowed. The reason to buy the DSM-5 is for the words in between the codes, not for anything that has to do with your practice or official reporting to third party carriers [or anywhere else]. It’s the textbook part that’s for sale, not the codes. You’ve already got them in your DSM-IV or on the Internet, and when they change ICDs in a few years, they’ll be widely available [a “how-to”…]:

While there’s much talk of a boycott which sounds like it’s some kind of active process that requires sacrifice, it’s more like holding on to your iPhone 4 instead of racing out for the iPhone 5 because you don’t care for the new features or are on a budget, or using Windows XP [as I do] instead of buying Windows 7.0 [or 8.0]. So if you want the new textbook according to the DSM-5 Task Force with their changes, buy it. Otherwise, follow the simple instructions of Zen Master Basho at the top of this post. The grass will continue to grow…
    Henry Hall
    February 15, 2013 | 1:01 PM

    Dear Mickey,
    it hardly matters whether you or I or your readership buys copies of the DSM-5.

    What matters is whether President Obama buys it. More exactly whether he takes executive action to require independent scientific review as a pre-condition of spending Federal dollars on DSM-5 and related publications.

    Persuade him to do that and the activists have it, Almost everyone will follow the leader.

    February 16, 2013 | 1:11 PM

    The current effective implementation date for ICD-10-CM is October 1, 2014.

    According to Page 3332 of this DHSS Office of Secretary Final Rule document, “We estimated that the earliest projected date to begin rulemaking for implementation of a U.S. clinical modification of ICD–11 would be the year 2020.” (Document dated January 16, 2009, at which point ICD-11 had been scheduled for WHA approval by 2014.)

    Ed: the date of 2014 for WHO approval by WHA has since been shifted to 2015.

    …We [ICD-9-CM Coordination and Maintenance Committee] discussed waiting to adopt the ICD-11 code set in the August 22, 2008 proposed rule (73 FR 49805)…

    …However, work cannot begin on developing the necessary U.S. clinical modification to the ICD–11 diagnosis codes or the ICD–11 companion procedure codes until ICD–11 is officially released. Development and testing of a clinical modification to ICD–11 to make it usable in the United States will take an estimated additional 5 to 6 years. We estimated that the earliest projected date to begin rulemaking for implementation of a U.S. clinical modification of ICD–11 would be the year 2020.

    The suggestion that we wait and adopt ICD–11 instead of ICD–10–CM and ICD–10–PCS does not consider that the alpha-numeric structural format of ICD–11 is based on that of ICD–10, making a transition directly from ICD–9 to ICD–11 more complex and potentially more costly. Nor would waiting until we could adopt ICD–11 in place of the adopted standards address the more pressing problem of running out of space in ICD–9–CM Volume 3 to accommodate new procedure codes…

    Source: Page 3332, Federal Register/Vol. 74, No. 11/Friday, January 16, 2009/Rules and Regulations DEPARTMENT OF HEALTH AND HUMAN SERVICES, Office of the Secretary [6]

    February 16, 2013 | 1:15 PM

    DSM-5 will already include crosswalked codes for ICD-10-CM, in readiness for October 1, 2014.

    Published a couple of weeks or so ago:

    DSM-5 Table of Contents [Lists finalized disorder sections and the categories that sit under them.]



    Highlights of Changes From DSM-IV to DSM-5

    Glossary of Technical Terms

    Glossary of Cultural Concepts of Distress

    Alphabetical Listing of DSM-5 Diagnoses and Codes (ICD-9-CM and ICD-10-CM)

    Numerical Listing of DSM-5 Diagnoses and Codes (ICD-9-CM)

    Numerical Listing of DSM-5 Diagnoses and Codes (ICD-10-CM)

    DSM-5 Advisors and Other Contributors

    February 16, 2013 | 4:48 PM

    The American Psychiatric Association seeks an accomplished Psychiatric Physician Executive to serve as Chief Executive Officer/Medical Director.

    February 16, 2013 | 5:10 PM

    In other news, the data WHO has been using to estimate the worldwide epidemic of depression is probably bogus:

    J R Soc Med. 2011 Jan;104(1):25-34. doi: 10.1258/jrsm.2010.100080.
    Global Burden of Disease estimates of depression–how reliable is the epidemiological evidence?
    Brhlikova P, Pollock AM, Manners R.

    Abstract at with free full text.

    February 16, 2013 | 6:28 PM

    Re: DSM costs

    The APA goes in a financial hole by spending 25 million bucks to promote the peddling of more drugs.

    Considering the *billions* pharma made from these drugs, by persuading psychiatrists to prescribe them… It would appear the APA membership could not only be called prostitutes, or even *cheap* prostitutes, but *money-losing* prostitutes!

    Psychiatry just can’t seem to get anything right.


    February 16, 2013 | 6:32 PM

    Just curious…

    Is there anyone within the APA leadership with a 3-digit I.Q.?

    If the APA wants to be taken seriously, that might be a good place to start.


    Bernard Carroll
    February 16, 2013 | 7:46 PM

    Thanks for that link, Alto. I am sure others have noticed that every Pharma-commissioned, ghostwritten article on antidepressants highlights those dubious WHO estimates – it’s like a ritual genuflection in the service of disease mongering. The same is true of many NIMH-sponsored publications out of projects like STAR*D.

    February 16, 2013 | 8:28 PM

    I’m sure it’s the basis for many government-sponsored programs to stamp out the spectre of depression, Dr. Carroll.

    February 17, 2013 | 12:28 AM


    Off-topic, back on the subject of alltrials:

    “Pharmaceutical companies indicated that they are moving to a policy of greater disclosure of clinical trial results regardless of outcome. Mary Anne Rhyne, director of US media relations at GlaxoSmithKline (GSK), told Drug Benefit Trends, “GSK agrees that public disclosure of clinical trial results for marketed medicines is essential and fully supports registration of all trials in progress. We have taken the following steps to demonstrate that commitment: GSK posts on the Internet results of all company-sponsored trials of all GSK-marketed medicines which we have completed since the formation of our company in December 2000—every trial, every phase, in every country.” She continued: “In many instances, when data from still earlier trials may inform medical judgment, those data have been posted as well. The data are presented in a consistent format without regard to whether they may be viewed as positive or negative.””

    Wait, so what’s been going on with GSK the past 5 years since that statement was made?
    This was from 5 years ago:

    And, in light of the quotes in that article from 2008, why haven’t the APA or the AACAP signed on to the alltrials petition? Is there some subtle difference between the statements they put out in 2004 and 2008 and alltrials?

    February 17, 2013 | 12:40 AM


    From 2004:

    So, two questions:
    What happened after this? It’s surprising they were this vocal. Am I missing something as to why they appeared to be so positively proactive? Was there some other pressure a work?
    And, since they said it publicly in 2004 and again in 2008, why have AMA, APA, and AACAP not signed alltrials now? Again, in the context of their having taken action before, what am I missing?

    February 17, 2013 | 12:48 AM

    What is alltrials adding into the mix that is making them more skittish?

    February 17, 2013 | 1:06 AM


    On a further off-topic note, this has remained completely anechoic:

    JAACAP’s final decision in December to never have further discussion of the 2001 paper.

    That’s clearly remained the most effective approach for them the past 10 years.

    Nothing that would cause them to regret the decision.

    Good read on their part.

    Bernard Carroll
    February 17, 2013 | 2:10 AM

    Well, AACAP happens to be one of the Allied Organizations recognized by the American Psychiatric Association. Here is the description from the APA website: Assembly Allied Organizations are professional organizations of psychiatrists with subspecialty skills and interest, whose mission and code of ethics are compatible with those of the American Psychiatric Association. After review of application of compliance by the Assembly Committee on Procedures, the Assembly votes to approve each Allied Organization. As of November 2011 there are 18 Assembly Allied Organizations.

    So, one point of leverage would be to work to persuade the APA to drop AACAP from its Allied Organizations on the ground that AACAP has not met the standard of accountability for the Glaxo Study 329 débacle. This would need to be initiated by an APA member in good standing, which rules me out – I resigned from APA over 20 years ago.

    February 28, 2013 | 5:00 AM

Sorry, the comment form is closed at this time.