Change Your Life: Illness

Showing posts with label Illness. Show all posts

Friday, June 3, 2011

Grief, mental illness and psychiatry’s sad refrain

Scientific American covers a coming shake-up in how grief is defined in relation to mental illness as the forthcoming DSM-5 diagnostic manual aims to radically redefine how mourning is treated by mental health professionals.

It’s worth saying that the DSM-5 has yet to be finalised and will not appear until 2013 but the changes to how grief is classified seem quite drastic.

Two proposed changes in the “bible” of psychiatric disorders—the Diagnostic and Statistical Manual of Mental Disorders (DSM)—aim to answer that question when the book’s fifth edition comes out in 2013. One change expected to appear in the DSM-5 reflects a growing consensus in the mental health field; the other has provoked great controversy.
In the less controversial change, the manual would add a new category: Complicated Grief Disorder, also known as traumatic or prolonged grief. The new diagnosis refers to a situation in which many of grief’s common symptoms—such as powerful pining for the deceased, great difficulty moving on, a sense that life is meaningless, and bitterness or anger about the loss—last longer than six months. The controversial change focuses on the other end of the time spectrum: it allows medical treatment for depression in the first few weeks after a death. Currently the DSM specifically bars a bereaved person from being diagnosed with full-blown depression until at least two months have elapsed from the start of mourning.

It is particularly striking that normal grief could be classified as a mental illness under the new proposals as this brings into question how we define mental illness itself.

Contrary to popular belief, there is not one ‘standard way’ of grieving and people’s response vary widely in response to losing a loved one. However, it’s true to say that being sad and withdrawn is certainly common enough for it to count as a normal reaction to loss.

This brings to mind psychologist Richard Bentall’s tongue-in-cheek proposal to classify happiness as a mental disorder due to the fact that it is “statistically abnormal, consists of a discrete cluster of symptoms, is associated with a range of cognitive abnormalities, and probably reflects the abnormal functioning of the central nervous system”.

Perhaps we can also look forward to simmering anger, dashed hopes and unrequited love disorders for the DSM-6?

Link to SciAm article ‘Shades of Grief’.

View the original article here

Sunday, February 6, 2011

Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness

Kabat-Zinn, founder of the Stress Reduction Clinic at the University of Massachusetts Medical Center, is perhaps the best-known proponent of using meditation to help patients deal with illness. (The somewhat confusing title is from a line in Zorba the Greek in which the title character refers to the ups and downs of family life as "the full catastrophe.") But this book is also a terrific introduction for anyone who has considered meditating but was afraid it would be too difficult or would include religious practices they found foreign. Kabat-Zinn focuses on "mindfulness," a concept that involves living in the moment, paying attention, and simply "being" rather than "doing." While you can practice anything "mindfully," from taking a walk to cleaning your house, Kabat-Zinn presents several meditation techniques that focus the attention most clearly, whether it's on a simple phrase, your breathing, or various parts of your body. The book goes into detail about how hospital patients have either improved their health or simply come to feel better despite their illness by using these techniques, but these meditations can help anyone deal with stress and gain a calmer outlook on life. "When we use the word healing to describe the experiences of people in the stress clinic, what we mean above all is that they are undergoing a profound transformation of view," Kabat-Zinn writes. "Out of this shift in perspective comes an ability to act with greater balance and inner security in the world." --Ben Kallen

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Sunday, January 9, 2011

The war of the manual of mental illness

Wired covers the battle raging over the next version of the ‘manual of mental illness’ – the American Psychiatric Association’s DSM-5.

The piece discusses how the chief editors of two previous version of the manual, Robert Spitzer and Allen Frances – who edited the DSM-III and DSM-IV, have heavily criticised the proposed new manual for lack of transparency in development (non-disclosure agreements are required) and for ever-widening categories.

We’ve covered the (surprisingly personal ) battle on a couple of occasions but the Wired piece does a great job of getting into the nitty gritty of the arguments.

What the battle over DSM-5 should make clear to all of us—professional and layman alike—is that psychiatric diagnosis will probably always be laden with uncertainty, that the labels doctors give us for our suffering will forever be at least as much the product of negotiations around a conference table as investigations at a lab bench. Regier and Scully are more than willing to acknowledge this.
As Scully puts it, “The DSM will always be provisional; that’s the best we can do.” Regier, for his part, says, “The DSM is not biblical. It’s not on stone tablets.” The real problem is that insurers, juries, and (yes) patients aren’t ready to accept this fact. Nor are psychiatrists ready to lose the authority they derive from seeming to possess scientific certainty about the diseases they treat. After all, the DSM didn’t save the profession, and become a best seller in the bargain, by claiming to be only provisional.

My only gripe with the article is it seems a little star-struck by the idea that mental illness could be validated or even wholly defined by reference to neuroscience, which is a huge category error.

How would we know which aspects of neuroscience to investigate? Clearly, the ones associated with distress and impairment – mental and behavioural concepts that can’t be completely substituted by facts about the function of neurons and neurotransmitters.

That’s not to say that neuroscience isn’t important, essential even, but we can’t define disability purely on a biological basis.

It would be like trying to define poverty purely on how much money you had, without reference to quality of life. We need to know what different amounts of money can do for the people in their real-life situations. Earning $5 a day is not the same in New York and Papua New Guinea.

Not even physical medicine pretends to have completely objective diagnoses, as, by definition, a disorder is defined by the impact it has.

An infectious disease is not solely defined by whether we have certain bacteria or not. First, it must be established that those bacteria cause us problems.

The urge to try and define all mental illnesses in terms of neuroscience is, ironically, more an emotional reaction to criticisms about psychiatry’s vagueness than an achievable scientific aim.

Link to article ‘Inside the Battle to Define Mental Illness’.

View the original article here

Friday, December 24, 2010

Plan Your Illness in Advance - Prepare With Pre-Authorization Frustration

Plan Your Illness in Advance - Prepare With Pre-Authorization Frustration | Psychology Today

True Grit is better than any film nominated for the Golden Globe Awards.

Stanton Peele

It's the demand for compulsory perfection at Christmas that's not natural.

Kate Distin, Ph.D.

The health insurance industry has labored to obstruct sensible use of medical services.

Matthew Edlund, M.D. Mark D. White PhD

When it comes to close personal relationships, forgiveness is essential.

Mark D. White, PhD

Men gossip to make themselves look better; women gossip to make others look worse.

Mark van Vugt, Ph.D.

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Recently Diagnosed?Diagnosis Dictionary Magazine Tests Psych Basics Experts Blogs The Power of Rest Why sleep alone is not enough–and how to reset your body. by Matthew Edlund, M.D. Plan Your Illness in Advance - Prepare With Pre-Authorization Frustration Thinking of getting sick? Prevention may prove your only cure. Published on December 23, 2010

Health Insurance Helps Insure You Won't Be Insured

Do you really think you have health coverage? Over decades the health insurance industry has labored to perfect methods that obstruct sensible use of medical services. Their abilities continue to improve. We should expect worsening care, higher prices, and a poorly served, frustrated population - including you.
Here's one very, very small but instructive example of how insurance obstruction works - the preauthorization "process."

My quest was to get a higher dose of a rather cheap generic antidepressant for a woman who'd been on the medication for years. Her diagnostic list was long, including sleep apnea, lupus, hypoadrenalism, and diabetes. In this case I was trying to persuade representatives from one of the many Blue Cross Blue Shield insurers, though my experiences with other insurers has been similar.
The pharmacy sent me a fax declaring I would need to get preauthorization through the health insurance company. The form included the listings of the patient's insurance card number and group. Here's how it went:

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I call a 1-888 number. A stalwart voice answers - the number has been changed. I must call a 1-900 number, and I will be charged $1.99 a minute.
Is Blue Cross really going to charge me two bucks a minute because I'm trying to get my patient a bit more of a generic drug?
I examine the form again with my office manager. In very small print there's another number we can call - an 1-800 number.
I call through. This one really does reach Blue Cross Blue Shield. After a wait, I'm switched through to voice mail which gives me several options for bill paying and checking charges. None of them have the specific option I'm calling for - so I hit the final option, "other."
I'm rerouted to the same message. I carefully listen to the options, hoping there's something that will give me a chance to get through to a person.
I'm disconnected. (That happens all the time.)

Keep Dialing

I call again. This time there's another option available for "doctors and doctor representatives." I pound the proper tones on the phone and get - the demand to call another number.
I call this new 1- 800 number. This time I'm requested to punch in the "ID" number of the patient without its first letter prefix. I have two insurance identifiers, but the only one with a prefix is for a group. I try it. I wait.
More numbers are requested, including my "NPI" number. I punch those in and - The phone is dialing something else. I listen to ads about the fine medical coverages available plus the option to take "just 30 seconds" to review my call experience when everything is finished.

Then - eureka - a human voice!

"Please tell us the patient's number, date of birth, and identity number."
I give these, but am further requested to give my "provider number" which is not the same as my NPI number. Fortunately, I can run out of my office again and find my office manager, who knows what this other number is.
I'm switched to another line. More ads, and more opportunities to later discuss my pre-authorization experience with another representative.
The next person I'm talking to sounds extremely bored, and requests the same information again. She wants to know if I am the "doctor's representative" and what my position is.
"I am the doctor."
Long silence.
More numbers are requested, including my Federal Tax ID number; the only number I know that they've left out is my Drug Enforcement Administration number - don't they want that? We are talking about a drug, after all. Again I give the patient's information.
"Did you already talk to Prime?"
Prime? Huh? "No," I say.
"You should have talked to them. I'll give you another number for them."
"They're not connected to you?"
"I can connect you." I take down the new number anyway.
More ads, more opportunities to talk with a representative about my review experience. Yet after a relatively short wait and no further disconnection I reach Prime!.
This "representative" is also surprised that I am the doctor calling for my patient. For the third time I'm asked to give the same patient information; I've already given my information four times. Do they need my Tax ID that badly?
Finally I receive my reward: "By the end of the day" I may receive a fax allowing me to explain my "clinical decision." I'm asked to give my fax and office numbers again.
"Why do you need this information again?"
"In order to make sure the fax goes through we need a backup number. Have you had any problems?"
"Yes. This whole system is a problem."
I've been on twenty-six minutes. And at the end of the day I might get a fax!
I opt not to discuss my review experience with another representative.

The Fax

Three hours later the fax arrives. On it is all the same information again, to be filled out longhand, plus a lot more.
I have to give all the patient's diagnoses; a history; all the reasons for selecting the medication and why alternatives cannot be used; and all the similar drugs she's been on, the dates and doses of when they were tried, why they didn't work; plus what other medications will be used in combination.
My patient has been on such drugs for decades. I have some of the information in my chart, but by no means all.
I will have to call her to get this information.

The Con

My experience is a tiny sampling of what millions deal with daily, frequently in life threatening forms. I know the potential results of even "successful preauthorizations." In one case I spent an hour on the phone attempting to get a generic drug okayed, finally obtaining agreement from the very concerned sounding health insurance pharmacist. However, the dose sent to the patient was one third what we agreed upon, a dose well below therapeutic level.
I understand that health care is complicated and expensive. I am willing to fill out paperwork explaining what my patients need, and am willing to talk to a pharmacist or "care manager" about why I am doing what I do.
However, this present system is clearly set up for obstruction aided by behavioral conditioning. In the old days they just sent the fax, without making you burn on the phone to get it. Instead, multiple requests for the same information are routine. Multiple phone disconnections are routine. I suspect the constant repetition while you wait of "opportunities" to review your "pre-authorization experience" is just a diabolical way to give the appearance of caring while infuriating people more.

Because the whole point of this process is to make you quit.

It works well. My physician friends don't bother any more. The patient in this example told me her internist refuses to do any pre-authorizations. Their PAs and medical assistants are also fed up.
Preauthorization for psychotherapy - don't even think about it.
So what happens to patients who are too sick or too disabled to call and defend themselves?
They pay up - or they don't get the treatment. And the insurance companies?
Big savings.

Who Pays?

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