Changes to ICD-10 Mental Health Codes October 1st

icd-10The mental health chapter of the International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10) will take effect October 1 and reflect the updated diagnoses in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
Each year on October 1, the International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10), is updated to reflect diagnostic changes in medicine.
The American Psychiatric Association has advocated that changes be made to ICD-10 to reflect the updated diagnoses in DSM-5. These include changes to align the terminology used in DSM-5 with that used in the mental health chapter of ICD-10. In response, the Fiscal Year 2017 version of ICD-10, which takes effect October 1, will include most of DSM-5’s terminology.

In some cases, new codes have been added to ICD-10 to accommodate the new diagnoses that were added to DSM-5. The new codes will allow more accurate diagnostic recording, improved communication among clinicians, and better means for collecting prevalence data.

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Sources: Psychiatric News
Printable PDF of new codes from APA

 

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FDA Approves Devices for Assessing Cognitive Function After Brain Injury

fdalogoThis week the Food and Drug Administration (FDA) has approved two computerized cognitive tests that can assess cognitive skills immediately following a suspected brain injury or concussion. The Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) and ImPACT Pediatric are the first medical devices permitted for marketing that are intended to assess cognitive function following a possible concussion. They are intended as part of the medical evaluation that doctors perform to assess signs and symptoms of a head injury.

According to the FDA, “ImPACT and ImPACT Pediatric are not intended to diagnose concussions or determine appropriate treatments. Instead the devices are meant to test cognitive skills such as word memory, reaction time and word recognition, all of which could be affected by a head injury. The results are compared to an age-matched control database or to a patient’s pre-injury baseline scores, if available.

ImPACT software runs on a desktop or laptop and is intended for use with those aged 12 to 59. The ImPACT Pediatric runs on an iPad and is designed for children aged 5 to 11. The FDA reviewed ImPACT through its de novo classification process, a regulatory pathway for novel, low- to-moderate-risk medical devices that are first of a kind and for which there are special and general controls to provide a reasonable assurance of safety and effectiveness of the devices.

FDA Announcement
ImPACT Applications

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Patients With Bipolar Disorder Wait Six Years Before Receiving Diagnosis and Treatment

CJPIn a new study published in the Canadian Journal of Psychiatry, researchers conducted a meta-analysis of 27 studies involving 9,415 patients and found that bipolar patients wait six years on average from the time their symptoms start to show up before they get proper diagnosis.

A meta-analysis that assessed studies reporting estimates of the age of onset (AOO) and indicators of the age at initial management of BD. The pooled estimate for the interval between the onset of BD and its management was 5.8 years A longer interval was found in studies that defined the onset according to the first episode (compared to onset of symptoms or illness) and defined management as age at diagnosis (rather than first treatment or first hospitalization). Recent studies that used a systematic method to establish the chronology of illness, among studies with a smaller proportion of bipolar I patients, and among studies with an earlier mean age of onset reported longer intervals.

The researchers concluded that “There is currently little consistency in the way researchers report the AOO and initial management of BD. However, the large interval between onset and management of BD presents an opportunity for earlier intervention.”

Canadian Journal Of Psychiatry
July 26, 2016

 

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Brainwaves and Text Messaging

eegNew research published in Epilepsy and Behavior shows that sending text messages on a smartphone can change the rhythm of brain waves.  People communicate increasingly via text messaging, though little is known on the neurological effects of smartphone use. A neurologist and director of the epilepsy monitoring unit and epilepsy center at the Mayo Clinic in Jacksonville, Florida found a unique EEG ‘texting rhythm’ in approximately 1 in 5 patients who were using their smartphone to text message while having their brain waves monitored.

While the use of smartphones has drastically increased within the past few years, little is known about their influence on neurophysiological processes. Researchers have observed more patients using personal electronic devices to communicate by text messaging during video-EEG monitoring. As a result, they have encountered a reproducible, stimulus-coupled, time-locked, 5–6-Hz, generalized, frontocentral-predominant, theta rhythm that occurs during active texting. The researchers define it as a texting rhythm (TR) evoked by the use of smartphones. This TR is unique to texting on personal communication devices and the study authors are unclear whether the TR reflects a benign form of midline frontal theta or a biomarker that may have application in industry or health care and certainly  merits further investigation.
Source:

Epilepsy & Behavior June 2016

 

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New Classification Scheme for Alzheimer’s Biomarkers

NeuroThe American Academy of Neurology is proposing a new classification scheme to describe Alzheimer’s biomarkers. Biomarkers have become an essential component of Alzheimer disease (AD) research and also in cognitive aging research. A number of current issues suggest that a new descriptive classification scheme for these biomarkers would be useful.

The proposed format is called  the “A/T/N” system in which 7 major AD biomarkers are divided into 3 binary categories based on the nature of the pathophysiology that each measures. “A” refers to the value of a b-amyloid biomarker (amyloid PET or CSF Ab42); “T,” the value of a tau biomarker (CSF phospho tau, or tau PET); and “N,” biomarkers of neurodegeneration or neuronal injury ([18F]-fluorodeoxyglucose–PET, structural MRI, or CSF total tau). Each biomarker category is rated as positive or negative. An individual score might appear as A+/T+/N-, or A+/T-/N-, etc.

Temporal ordering of mechanisms underlying AD pathogenesis are ignored. It includes all individuals in any population regardless of the mix of biomarker findings and therefore is suited to population studies of cognitive aging. It does not specify disease labels and thus is not a diagnostic classification system. It is a descriptive system for categorizing multidomain biomarker findings at the individual person level in a format that is easy to understand and use. Given the present lack of consensus among AD specialists on terminology across the clinically normal to dementia spectrum, a biomarker classification scheme will have broadest acceptance if it is independent from any one clinically defined diagnostic scheme.

Source: Neurology® 2016;87:1–9

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Natural Molecule Can Improve Parkinson’s Disease

PLOS-ONEResearchers from the Departments of Integrative Medicine, Neurology, and Radiology, at Thomas Jefferson University have demonstrated that the natural molecule, n-acetylcysteine (NAC), with strong antioxidant effects, shows potential benefit as part of the management for patients with Parkinson’s disease. Published in PLOS ONE, the combination clinical evaluations of a patient’s mental and physical abilities along with brain imaging studies that tracked the levels of dopamine,  both improved in patients receiving NAC.

Recent research has shown that oxidative stress in the brain may play a critical role in the Parkinson’s disease process, and that this stress also lowers levels of glutathione, a chemical produced by the brain to counteract oxidative stress. Studies in brain cells showed that NAC helps reduce oxidative damage to neurons by helping restore the levels of the antioxidant glutathione. NAC is an oral supplement that can be obtained at most nutrition stores, and interestingly also comes in an intravenous form which is used to protect the liver in acetaminophen overdose.

In the study, compared to controls, the patients receiving NAC had improvements of 4-9 percent in dopamine transporter binding and also had improvements in their Unified Parkinson’s Disease Rating Scale (UPDRS) score of about 13 percent. According to the researchers “we have not previously seen an intervention for Parkinson’s disease have this kind of effect on the brain.” The investigators hope that this research will open up new avenues of treatment for Parkinson’s disease patients.

Reference
Monti, DA, et al. PLoS One. 2016 Jun 16;11(6):e0157602.

 

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New Practice Guidelines on the Use of Antipsychotics in Dementia

A new guideline from the American Psychiatric Association is designed to improve the care of patients with dementia who are exhibiting agitation or psychosis. More specifically, this guideline focuses on the judicious use of antipsychotic medications when agitation or psychosis occurs in association with dementia. It does not review the evidence for other pharmacological interventions. The guideline is intended to apply to individuals with dementia in all settings of care as well as to care delivered by generalist and specialist clinicians. Recommendations regarding treatment with antipsychotic medications are not intended to apply to individuals who are receiving antipsychotic medication for another indication (e.g., chronic psychotic illness) or individuals who are receiving an antipsychotic medication in an urgent context.

The guideline is available online.

The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia

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Mixed Depression May Be More Common Than Previously Thought

AJPMixed states are characterized by concurrent manic and depressive symptoms. The concept of a “with mixed features” specifier for major depressive episodes was introduced in DSM-5 and defined by the presence of at least three nonoverlapping opposite-pole symptoms in the context of a syndromal depressive, hypomanic, or manic episode. There has been growing interest in the phenomenology and clinical implications of the opposing mixed state—that is, manic or hypomanic symptoms during a depressive episode. A study published in the American Journal of Psychiatry assessed the prevalence and features of mixed depression among bipolar disorder patients and qualitatively compared a range of diagnostic thresholds for mixed depression.

Visit outcomes of adult outpatients (N=907) with bipolar disorder across 14,310 visits between 1995 and 2002 were analyzed. At each visit, mania and depression symptoms were assessed using the Inventory of Depressive Symptomatology–Clinician-Rated Version (IDS-C) and the Young Mania Rating Scale (YMRS). Patients with an IDS-C score of greater or equal to 15 and a YMRS score between 2 and 12 at the same visit were classified as having mixed depression. The presence of mixed depression was observed in 2,139 visits (14.9% of total) and among 584 patients (64.4% of total). Those classified as having one or more mixed depression visits also had more symptomatic visits and fewer non-depressed visits compared with those with no mixed depression visits.

The authors concluded that among the patient population studied, depressive symptoms were common, and subthreshold hypomania occurred in almost half of all visits with depression. The study revealed that women were more likely than men to experience hypomanic symptoms concurrently with depression across a range of diagnostic criteria for mixed depression. “The presence of mixed depression appears to be a marker of vulnerability to mixed depression features in general and may portend a more symptomatic course of illness over time. The stability of our mixed depression construct across a range of definitions supports the possibility that broader diagnostic criteria for mixed depression may improve sensitivity while preserving clinical meaningfulness.”

Source: American Journal of Psychiatry
Published Online April 15, 2016

 

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No Changes to Maintenance Of Certification for Psychiatry, Neurology

A number of medical boards are in the process of reviewing their maintenance of certification (MOC) requirements and steps.  Jeffrey Lyness, MD, psychiatry director for the American Board of Psychiatry and Neurology (ABPN), professor of psychiatry and neurology, and senior associate dean for academic affairs at the University of Rochester School of Medicine and Dentistry, in New York, presented at the American Association for Geriatric Psychiatry (AAGP) 2016 Annual Meeting this month and reported that the ABPN is not likely to make any major changes anytime soon to the MOC process. There were some minor changes for 2016 making the requirements for Part IV, the Improvement in Medical Practice module, which is also known as the Performance in Practice (PIP) module, more flexible.

For the PIP this year, ABPN diplomates can choose either a clinical or a feedback module. In 2015, the clinical module was required, and in 2014, diplomates were expected to do both. Psychiatrists can receive clinical module credit for a wide variety of activities, including completing institutional quality improvement (QI) activities, completing professional QI activities, such as participating in registries, and through meaningful participation in the American Board of Medical Specialties’ (ABMS’) Portfolio Project. Completion of the “Feedback module” requirements can be met through patient or peer surveys, for example, institutional peer review and supervisor evaluation.

Part IV is a three-step process that includes initial assessment, identifying areas that need improvement and implementing an improvement process, and then undertaking a reassessment. Another new requirement beginning in 2016 is that psychiatrists who are being certified or recertified must take a patient safety course. The ABPN will be listing approved courses on its website.

Sources:

Lyness JM. Update On Geriatric Psychiatry Maintenance Of Certification Program. Journal of the American Association For Geriatric Psychiatry.2016;24(3) Supl 1. Abstracts from the 2016 AAGP Annual Meeting. Washington, DC. March 17–20, 2016. Session 207.

Ault A. MOC: No Changes for Psychiatry, Neurology Anytime Soon. Medscape Medical News. Website http://www.medscape.com/viewarticle/860742. Published March 22, 2016. Accessed March 22, 2016

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Antipsychotic Use in Parkinson’s Disease Associated With Mortality Risk

JNA new study by researchers at the Perelman School of Medicine at the University of Pennsylvania, the University of Michigan Medical School, and the Philadelphia and Ann Arbor Veterans Affairs (VA) Medical Centers and suggests that antipsychotic drugs may do significantly more harm in a subset of Parkinson’s patients.

An analysis of approximately 15,000 patient records in a VA database found that Parkinson’s patients who began using antipsychotic drugs were more than twice as likely to die during the following six months, compared to a matched set of Parkinson’s patients who did not use such drugs. Over a decade ago the FDA has mandated “black box” warnings on antipsychotic medications, noting that there is an increased risk of death when these drugs are used in dementia patients. In the new study, researchers examined the possibility that antipsychotic drug use is associated with higher mortality not just in Parkinson’s dementia patients, but in all Parkinson’s disease patients. The analysis revealed that in the 180 days after they first took antipsychotic drugs, patients in the first group died in much larger numbers, compared with the matched control patients during the same periods. Overall the Parkinson’s patients who used antipsychotics had 2.35 times the mortality of the non-users.

Antipsychotics have been used to manage psychosis that can accompany Parkinson’s disease. The underlying causes of psychosis in Parkinson’s are not well understood, but are thought be the result of the spread of the neurodegenerative disease process to certain brain areas, as well as from higher doses of Parkinson’s drugs that enhance dopamine function. The researchers recommend that for the present, neurologists and other physicians should prescribe antipsychotics to Parkinson’s patients only after looking for other possible solutions, such as treating any co-morbid medical conditions associated with psychosis, reducing the dosage of dopamine replacement therapies, and simply managing the psychosis without antipsychotics.

Study

Weintraub D, et al. Association of Antipsychotic Use With Mortality Risk in Patients With Parkinson Disease. JAMA Neurol. 2016 Mar 21.[Epub ahead of print] PMID:26999262

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