So, let’s say that [hypothetically] that you thought the DSM-5 effort was misguided and wanted no part of it [hypothetically]. What could you do? Well, first, you could read this article that quotes Dr. Michael First, particularly the pieces highlighted in red:
DSM-5 In the Homestretch—1. Integrating the Coding Systems
Psychiatric Times
By James Phillips, MD
March 7, 2012
…There are, in case you have forgotten, two classificatory systems of mental disorders—the International Classification of Diseases (ICD), produced by the World Health Organization (WHO), and the Diagnostic and Statistical Manual (DSM), produced by the American Psychiatric Association. How are they related? It is a question that has confused me, and I assume, some of my psychiatric colleagues as well as others—other mental health professionals, and still others. For an answer to this question I asked Michael First, MD, Editor of DSM-IV-TR, Consultant on the WHO ICD-11 revision, and someone who knows much more about these matters than most of us. Here is his response to what I put as a question that could lend itself to a quick answer.
Dr First: I wish I could give you a quick answer, but as with any question about the coding, I need to give the background first.
This is how it works. The only official coding system in the United States is the ICD, produced by the WHO. The US has a treaty obligation to report health statistics using the ICD system. The US is still using a "clinical modification" of the WHO’s ICD-9 system (released in 1978) called ICD-9-CM. The diagnostic codes that appear in the DSM-IV are all legal ICD-9-CM codes. Clinicians fulfill their obligations to use the ICD-9-CM coding system by using the DSM-IV. When DSM-IV created its few new disorders, which were obviously not in the ICD-9-CM, the APA could either assign an existing ICD-9-CM code (which might be already used for another DSM-IV disorder, in which case multiple disorders would share the same code), or else request that the US Government to add a new code to the ICD-9-CM system (such a provision exists in the ICD-9-CM system to accommodate newly discovered or new subtypes of diseases), which is a year-long process.
When assigning an existing code, we would pick the code that was closest to the phenomenology of the new disorder. For example, ICD-9-CM had a code for "depressive neurosis," which was then assigned to the DSM-III disorder "dysthymia," because that ICD-9-CM concept came closest to the DSM-III concept. More often, for a category that was not really reflected in the ICD-9-CM at all, we would assign an "other" code, which are available throughout the ICD-9-CM precisely to accommodate the addition of new disorders. So for Bipolar II Disorder, which we added to DSM-IV, we picked the code 296.89, which corresponded to "Other Bipolar Disorder" in ICD-9-CM.
For DSM-5, the same general rule applies. For new diagnoses such as Attentuated Psychosis Syndrome, APA would need to look at the existing system and either find some category that corresponded most closely to this condition (although it is not clear to me that there is any such condition already in ICD-9-CM), or else assign some "other" code; perhaps the code for "Other Psychotic Disorder," although even that would be a stretch since, by definition, these individuals are not psychotic. Even though the newly assigned code may not up conceptually match very well to the existing ICD-9-CM entity, from a practical perspective it doesn’t matter—insurance companies seem to accept and pay for most ICD-9-CM codes no matter what they are, unless they have been specifically excluded by the insurance company. For example, perhaps an insurance company would want to refuse payment for treatment of personality disorders; they could exclude any of the codes for personality disorders.
Further complicating matters is the recent news that implementation of ICD-10-CM is being delayed from October 2013 to God knows when. Originally, DSM-5 was planning to include ICD-10-CM codes to be compatible with the requirement that clinicians use ICD-10-CM codes starting in October 2013 (5 months after publication of DSM-5). Now that there will be a delay, DSM-5 will need to use ICD-9-CM codes (ie, those in the DSM-IV), instead.
You could simply not buy a copy of the DSM-5 [let the APA hold on to your copy in their warehouse], and use the ICD-9-CM Codes in your ICD-9 or DSM-IV and just go on living your life exactly like you are now. I guess you could call that ignoring the DSM-5. And what if they’ve added new Diseases, Disorders, and other things? Could you ignore those things too?
The only official coding system in the United States is the ICD, produced by the WHO. The US has a treaty obligation to report health statistics using the ICD system. The US is still using a "clinical modification" of the WHO’s ICD-9 system (released in 1978) called ICD-9-CM… Now that there will be a delay, DSM-5 will need to use ICD-9-CM codes (ie, those in the DSM-IV), instead.
Like it says:
…from a practical perspective it doesn’t matter—insurance companies seem to accept and pay for most ICD-9-CM codes no matter what they are, unless they have been specifically excluded by the insurance company. For example, perhaps an insurance company would want to refuse payment for treatment of personality disorders; they could exclude any of the codes for personality disorders.
So is the DSM-5 superfluous, practically speaking [hypothetically]?
Thank you for this analysis, Mickey. I have long thought that DSM-III and DSM-IV ranked among the classic confidence jobs of the 20th Century.
The American Psychiatric Association has made many millions of dollars from selling the DSM volumes (think around $5 million per year since 1980) even though, as you describe, the DSM volumes were not really needed. They contributed no added value to the ICD codes. They are not scientific documents – there is no argument about that. I see no reason for great expectations that DSM-5 will be any different.
I might be wrong but I think Medicare and Medicaid require ICD9CM codes– they don’t use DSM at all. So let the APA screw themselves by making up codes not compatible with ICD10CM! Who really cares about DSM? I mean no clinician really uses it. And the ICD9CM is easy for billing purposes.
It does seem that DSM-anything is window-dressing administratively.
I think the solution to the DSM mess is simple: Let’s just boycott buying the bible. If no one buys it, then it doesn’t really matter.
fyi
http://www.reuters.com/article/2012/03/23/us-depression-drugs-idUSBRE82M0MK20120323
Insight: Antidepressants give drugmakers the blues
“Data from Thomson Reuters Pharma shows returns for pharmaceutical companies in the antidepressant market are collapsing – despite widespread use of pills like Prozac – as patents expire and new drugs fail to make it to market.
Some Big Pharma firms are quitting the field altogether. Others are hacking back investment and shedding jobs.
These might seem like prudent decisions in an increasingly expensive and frustrating field…”
From the article jamzo linked to:
Since emotional disorders such as depression and anxiety are linked with hyperactivity of the amygdala, this is thought to have an almost immediate but subconscious effect on reducing patients’ negative responses.
“So now we have this new theory – and it has quite a bit of evidence now – that what antidepressants do is to change cognitive bias so that people start to see the world as a more positive place,” said Nutt.
If we just understood how sick we are, they could fix us— if they could just understand how we are sick. We probably just need an anti-psychotic, a neuroleptic, an anti-depressant, and a benzo; and to learn a few neat cognitive tricks like always making excuses for other people and blaming our way of thinking when things go wrong.