Friday, August 20, 2010

The Madness of Multi-axial Diagnostic System in Psychiatry

About eight months ago I had a site-visit by a Behavioral Management Company (BMC) contracted by a Medicaid HMO to keep down service costs. In other words, this company is contracted to find ways to minimize a patient's visit to doctors and other medical activities. Ostensibly it's contracted to perform the above tasks, but in practice it is to cut down medical consumption across the board whether for good or for greed. The purpose of this particular site visit was to use a little fear mongering because I did not fit their mold.

It is very unusual in the world of psychiatry to include psychotherapy as part of patient treatment. Today's standard practice is for the psychiatrist to quickly make some monolithic diagnosis such as Major Depression or Schizophrenia or Bipolar Disorder, write a few prescriptions, and hand over the patient to a social worker or psychologist to then tinker with their mind. A psychiatrist's role is limited.

I find something drastically wrong with this picture. In such a system the psychiatrist is unlikely to allow any patient who comes his way to escape without putting him on at least one medication. If the patient does not respond to the first medication, in all likelihood the psychiatrist will keep adding more and more medications until the patient, if not healed, is at least completely out of it. I do my own psychotherapy with my patients and do not split my patient's treatment with therapists. I manage not only their medications, but their psychological world as well.

The BMC was not happy with such a state of affairs. They were not unhappy that I was getting good results. They were not unhappy because I was prescribing medications very sparingly (which alone saves them tons of money). They were not unhappy because I rarely admit patients (which again saves tons of money). They were not unhappy because my patients are not unhappy with my psychotherapy or my medication management. They were not unhappy because Medicaid was not saving money by my doing both aspects of treatment: medications and therapy.
So, what was making this BMC so unhappy?

The BMC was unhappy because my patients were happy seeing me and almost all of them wanted to avail themselves to the full 20 sessions allotted annually by Medicaid. The BMC prefer to utilize therapists who are so poorly trained and are so stinking bad that people would rather commit suicide than have a psychologist see them beyond a few sessions.

The BMC had decided that as a psychiatrist I was not authorized to bill for psychotherapy; I could only bill code 90862 (medication management) which reimburses $27.00. I could not bill code 90806 that pays $54.00 for a full session. The BMC stated that code is reserved for psychologists and social workers. When I offered the services to do psychotherapy, bill code 90806 and throw in the medication management for free, I was told there is no such thing as a psychiatrist doing psychotherapy without tinkering with the patient's medications and for that I would have to bill code 90807 to receive $32.00 because the BMC does not think psychiatrists are capable of doing psychotherapy. When I stated I would take this issue to the Mental Health Board and to the American Psychiatric Association they decided to do another site visit in an attempt to scare the bejeezus out of me.

The social worker who visited to review my charts was pleasant and was astonished that most of my records were primarily analyses of patients' dreams. She was very impressed with that. She had seen nothing like it in her entire career. That must have been a mind blower. Nevertheless, since I failed to make the five-storied multi-axis diagnoses at the end of psychiatric evaluations, I was faulted. Her notes read, "This psychiatrist appears to be capable of making the five-storied multi-axial diagnoses when he chooses as he does when filling forms for disability or sending reports to courts, but he does not do so for his clinical work and this is a serious lapse."

Now is it? Really?

The five-tiered diagnostic system that the American Psychiatric Association has thrown at the psychiatric profession like the ten plagues of Egypt is the biggest heap of bull ever crapped upon a profession and on patients who must adhere to that discipline for their treatment.

Yes, yes, it does make the psychiatrist feel he has done a wonderful job of evaluating his patient and he can feel so without having a whit of understanding what is really wrong with that patient.
It gives the psychiatrist a sense of having done something very complete, something very profound, something very complex, something that looks so long and mighty in comparison to a one or two word diagnoses of other medical specialties; and he can get that "feel good all over" feeling without having done anything really meaningful.

Diagnostic labels have no real meaning in psychiatry, no matter which DSM diagnostic category they belong to. Every symptom, complaint and problem has to be deciphered on its own right, regardless of what diagnostic rubric it is subsumed under.

For example, if one is diagnosed as having depression, it is no big feat. Anyone with even the most elementary clinical sense and a modicum of intelligence can make that out if a person is listened to for even a few minutes. As far as psychopharmacology is concerned we treat all forms of depression with the same broad brush; the same psychopharmacological agents. When one goes to other diagnoses, like obsessions or disturbances of the periodicities of mood (various forms of manic-depressive illnesses), the story is exactly the same. Making the diagnosis is child's play.

The difficulty is getting behind the diagnosis to figure out why the patient became depressed and what difficulties the patient is trying to master with the periodic mood shifts. What is the meaning of his obsessions and what contradictory impulses is the patient trying to express through his obsessive thinking and compulsive actions? These tasks, unfortunately, are not made easy, but become even more difficult when one must think through the foggy glasses of the multi-axial system.

In fact, once one makes a complete diagnosis with its impressive five or more lines, there is no motivation left to do anything more with patient's complaints. Now, even if one grants that the Axis I and the primary psychiatric diagnoses have some value, at least for the purpose of coding and billing, and as scaffolding for broadly conceptualizing patients' problems at gross level, the other Axes are totally useless if not outright harmful.

Axis II, the personality disorders, have no specific psychopharmacological agents that alter them. As far as psychotherapy is concerned it is outright nonsense to say that the therapists use one form of psychotherapy for one personality disorder and something else for another.

Axis III is a joke among therapists. Only medical doctors are truly capable of filling that section correctly. No psychiatrist performs thorough physical examinations. When it comes to writing that section of the multi-axial system the only thing the psychiatrist does is throw in a couple of patient's medical problems as an afterthought. The medical problem to mention is the same as picking a rabbit out of a hat. No attention is ever given to it again.

Axis IV is even more ridiculous. Naming a couple of psychosocial stressors and guessing their severity doesn't have any meaning in actually comprehending the patient's real life situation. These factors cannot be captured in one or two lines. By declaring that the stressor is legal versus marital versus school based, has no relevance to how one approaches patients. Does saying it is a very severe stressor versus a moderately severe stressor change one's approach to handling the patient? Does any psychiatrist ever declare a patient has less than moderately severe stressors.

Axis V is a worthless apex other than knowing some broad markers like Medicare will object to paying for inpatient care unless the GAF score is less than 40. In fact, it is now a clinician's game to start with a ridiculously low initial GAF score and gradually peg it upwards on paper to show progress.

The multi-axial diagnostic system in psychiatry is the biggest hoax and monstrosity perpetrated upon mental patients by the American Psychiatric Association. It was done at the behest of the pharmaceutical industry and it has primarily benefited them. With the advent of the multi-axial system psychiatrists slowly but surely abandoned listening to patients beyond getting enough information to pigeon-hole them into the DSM multi-axial system and then start medicating him as if there is no tomorrow.

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