<p>I’m a mental health provider who is not a prescriber. But my clear impression–and over the years I’ve become able to predict their scripts–is that there is a lot of trial and error involved. Kind of like, let’s start with Zoloft, and if that doesn’t work we will either modify the dosage or go with Prozac. This makes some sense, since people aren’t machined parts, and one size does not fit all.</p>
<p>That said I often wonder how much attention they actually pay to the elaborated DSM symptoms. There’s a lot of labeling that carries through. Someone identifies you or you self-identify as “depressed” and they’ll give you anti-depressants for life without deliberating on whether you match up with the diagnostic category. </p>
<p>I’ve seen many elderly patients with the diagnosis of dementia who get the utterly useless anti-dementia drugs, when a simple intellectual screening rules out the diagnosis. </p>
<p>Inertia is one of the biggest unstated DSM criteria. I doubt that a new DSM–and this could be a good study if it has not already been done–will change the behavior of most practitioners. (I find studies of how health care providers behave to be fascinating. There is little adherence to evidenced based practice. Most provider behavior can be predicted by their own history.)</p>
<p>I agree with those here who say that insurance reimbursement has much to do with the use of the DSM. In working with a patient, I mostly rely on training and experience, rarely on the DSM. I usually consult it only when I can’t remember the code number or I am looking for a reasonable one for billing and reimbursement. I think most colleagues are the same. The only time I carefully consulted the DSM was in grad school and training.</p>
Sorry. Dont agree with this one. First, current meds for dementia patients are hopefully to slow the progression of the disease process, not to treat the underlying diagnosis.And an IQ screen does not diagnose any of the multivariate dementia processes.</p>
<p>"We found repeatedly that, when treating supposed dually diagnosed patients for their substance abuse problems, the mental health diagnosis would disappear. The mental health professionals would insist that it was “in remission”; the substance abuse people would say that it wasn’t there to begin with.</p>
<p>If treated for mental health difficulties first, chances are the patients would never get well."</p>
<p>I am interested in learning more about your findings mini—my experience working with dually diagnosed addicts for a number of years found that they definitely needed the addiction treated as the primary illness, but if the mental health issue was not addressed they invariably relapsed. I found if you could stabilize the addiction, get them into early recovery, you could then begin the work on the other issue, of course there are many variations depending on the second diagnosis, depression, bipolar disorder, ptsd. for example many female addicts were sexual abuse survivors, and once they became clean and sober if they didn’t address this psychological issue they relapsed.</p>
<p>Didn’t say they pretend to treat the underlying process, but they do pretend to slow the progression of the disease process, which they don’t do in any meaningful way. I could cite many studies, but one of the key documents for FDA approval of Aricept showed a 3 item difference on a 70 point cognitive scale. I recommend this as a prime example of how a statistically significant difference doesn’t entail a meaningful real-world difference. Another study: in the UK, they compared people with moderate dementia with and without Aricept. The Aricept group–over a two-year period–entered nursing homes a whopping two weeks later than the control group. </p>
<p>Because of such studies, in the UK, Aricept is only allowed for mild to moderate dementia, and must (I believe) prescribed only by a psychiatrist or neurologist specialist–not by a primary care physician. Namenda is out of the formulary, allowable only for research. </p>
<p>Those drugs are simply not worth it. Hand out sugar cubes, and divert the billions to research or care. </p>
<p>I agree that an intellectual screening alone is not always sufficient for a dementia diagnosis–although I’ve found it rare that a person with a perfect score should get that diagnosis. It is important to separately evaluate memory function, social intelligence, and activities of daily living. </p>
<p>But many are misdiagnosed, and once you get a label, it can be as hard to remove as a tattoo.</p>
<p>You called them anti-dementia drugs. There are no such things.</p>
<p>I just saw a pt with a 135 IQ on testing. He had MCI- circumscribed amnestic type. Would have been completely missed with an IQ test alone. Nor would an IQ test pick up cognitive symptoms associated with : Corticobasal degeneration, Creutzfeldt-Jakob disease, HIV-related cognitive impairment, Huntington’s disease, multiple sclerosis, Niemann-Pick disease type C, normal pressure hydrocephalus., Parkinson’s disease, posterior cortical atrophy. progressive supranuclear palsy, to name a few.</p>
<p>** Also, can you clarify what a “perfect score” on an intellectual test is? There are mini mental status screens, but those aren’t IQ tests.</p>
<p>“I am interested in learning more about your findings mini—my experience working with dually diagnosed addicts for a number of years found that they definitely needed the addiction treated as the primary illness, but if the mental health issue was not addressed they invariably relapsed.”</p>
<p>Same. But you ALWAYS had to do the substance abuse treatment first, and you couldn’t even accurately diagnose a mental health problem until then. Some then are found not to have a mental health problem at all (as per the case where the state hospital kept someone for nine years, and true for 11% of their population with supposedly severe mental illness requiring hospitalization - a much larger proporrtion of those not requiring hospitalization); some have likely been “self-medicating” (but we have not found this to be a very large proportion); and some will be amenable to treatment after their substance abuse has been treated successfully (usually after several episodes - among state-paid patients, a mean of 3.5 episodes.)</p>
<p>"The true story of why the DSM was created to begin with is an interesting tale, but it would hijack the thread. "</p>
<p>I think a discussion of the history of the DSM is appropriate here, as is a discussion of the history of how mental illness is managed and paid for, here and in other countries. </p>
<p>This was brought up on a psychiatry forum, also titled something similar. Actually it was “Rats leave a sinking ship” or something similar, as the person who started the thread likes to get everyone going. I felt the links he added reflected good feelings about where we are going, but acknowledgement of where we are. </p>
<p>"This comes just weeks before the final publication of the latest edition of the American Psychiatric Association’s (APA) DSM – the notorious DSM-5.</p>
<p>In response to this, the APA released a statement saying, in essence, “Come back when you’ve actually done it; until then, we’ll carry on.”</p>
<p>and</p>
<p>New York Times Sunday Review; “Opinion Why the Fuss Over the D.S.M.-5?”</p>
<p>"So why the fuss over D.S.M.-5? Because of the unwarranted clout that its diagnoses carry with the rest of society: They are the passports to insurance coverage, the keys to special educational and behavioral services in school and the tickets to disability benefits. "</p>