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Appropriateness usage of ICD 10 CODES and Clinical Formulations
- Devender singh Yadav (21 July 2009)
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Beyond EBM?
- Anita D. Damle (27 July 2009)
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Devender singh Yadav, Staff Grade Psychiatrist None
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dsyadav{at}doctors.org.uk Devender singh Yadav
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The medicalisation or pathologising of normal experience and normal distress described by the author will strike a cord with those working in crisis resolution and home treatment teams and within general adult psychiatry. Kirsch’s meta analysis [1] points that antidepressants are useful only when the depression is severe reminding us that antidepressants don’t and can’t treat social problems. There were 31 million prescriptions for antidepressants written in the U.K in 2006(The week in numbers,BMJ,July 2009,vol 339). Proposals for massive expansion of psychological therapies will be counterproductive across society serving to medicalise social problems. [2] As suggested by the author Adjustment Disorder or Dysthymia could be the more appropriate codes, rather than Major Depressive Episodes. But in many cases other ICD10 [3] codes might be used such as in chapter XX; V01-Y98 (External causes of morbidity and mortality, for example X60- X84- Intentional self harm) or in chapter XXI; Z00-Z99 (Factors influencing health status and contact with health services, for example Z55-Z65; Persons with potential hazard related to socio-economic factors- psychosocial circumstances) would be more appropriate. How often do we use such codes? If used appropriately, then there are less chances of wrongly diagnosing social problems. No two patients with Major Depressive Episode are the same and to differentiate the two, clinical formulations of patients based on predisposing, precipitating and perpetuating factors are useful. Clinical formulations highlight both longitudinal and cross sectional aspects. The only problem in using clinical formulations is their limited usefulness for research in quantifying the prevalence and incidence of a particular disorder. The problem with classification of such heterogeneous condition as depression will, I suppose remain but a way forward is proposed by Ghaemi (2009) who writes, following Osler "When disease is present, one treats the body; where disease is ameliorable but not curable, one still treats with attention to risks; and where no disease exists (some patients have symptoms or signs, but no disease, e.g. cough, rather than pneumonia) one attends to the human being as a person. This approach (which captures the Hippocratic aim: to cure sometimes, to heal often, to console always)" is a perfect blend of science and arts, i.e. psychiatry. References: 1. Kirsch I, Deacon BJ, Huedo-Medina TB, et al (2008) Initial severity and antidepressant benefit. A meta-analysis of data submitted to the Food and Drug Administration.PLoS Medicine; 5:e45-8. 2. Summerfield, D., Veale, D., 2008, Proposals for massive expansion of psychological therapies would be counterproductive across society. BJP; 192(5) 326-330. 3. World Health Organization (1992) Classification of Mental and Behavioural Disorders. Clinical Descriptions and Diagnostic Guidelines (10th edition) (ICD-10). WHO. 4. Ghaemi SN. (2009) The rise and fall of the biopsychosocial model. BJP; 195(1):3-4 |
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Anita D. Damle, Consultant Psychiatrist St. Andrews Healthcare
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adamle{at}standrew.co.uk Anita D. Damle
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I found the current Advances a stimulating and positive experience as it seems to contain issues broader than only “the scientific” approach to the treatment of psychiatric/psychological problems. In the current climate of “evidence-based “ everything, it is refreshing to read Professor Jacob’s(2009) analysis of the usefulness and fall outs of categorical approach to classifying depression. Looking for the meaning of depression and not simply “tick boxing” people into DSM or ICD diagnoses, in my view, needs to be central to our approaches in treating people with depression. The SSRIs are indeed not the answer to many of life’s miseries. On a separate note, the paper by Claire Oakley et al(2009) made a lot of clinical sense and seemed to reflect the reality in patients under my care in low secure forensic wards. Many patients with the diagnosis of “treatment resistant schizophrenia” have improved with the addition of an SSRI, especially as regard to their irritability and anger/ hostility. Our experience has been anecdotal, not controlled, not in a research setting and therefore I am sure would be seen as worthless but the patients have benefited and treating underlying affective component has enabled them to engage in other therapeutic activities improving their quality of life. Maybe we are entering “post evidence based” era? If so it is most welcome. References: Clare Oakley, Fiona Hynes, and Tom Clark: Advances in Psychiatric Treatment 2009 v. 15, p. 263-270 Anita Damle. Consultant Psychiatrist, St. Andrews Healthcare, Northampton |
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