The insurance won’t pay without a diagnosis.
It’s very sad, but this is a fact that we have to live with. A clinician may feel that a patient can use legitimate help, but due to constraints of their insurance, they won’t be able to receive any help unless the clinician ticks the right boxes. And more times than not, ADHD or bipolar are the right boxes. Take Texas Medicaid for example. For adults, Medicaid won’t pay for outpatient
services unless there is a diagnosis of Major Depression, Bipolar, or schizophrenia. So in order for clinicians to help people who legitimately need help, they are forced to shoehorn a diagnosis where something different may be more appropriate (and more clinically sound) in order to be reimbursed by the insurance company.
For kids, in addition to the big three, they can also have ADHD.
Is this fraud? Is this necessary to stay in business … rather than showing people who really need help the door? What’s more ethical: making sure people get help when they really truly need it, or giving the right diagnosis? These insurance shenanigans are one of the primary reasons that the position of Pursuit of Happiness is to not take any insurance other than for our foster care program. We want our clinicians to do what they feel is clinically sound, not what they think they can get paid for, and we don’t want to put ourselves in the position of having to make a decision between giving someone a diagnosis we are not
comfortable with or giving them no treatment at all.
So if you look at it this way, the clinician’s culpability isn’t alone in the rampant overdiagnosis of these disorders. Our current reimbursement model for everyone in mental health (and I would posit the larger healthcare system as well) is broken, and some of the blame has to be placed with insurance carriers as well.
To play devil’s advocate however, an insurance company must outline a threshold of criteria to adhere to. Otherwise shady clinics would bill them for all they’re worth and the insurance company would be out of business.
Not all clinicians are created the same and not all clinicians are so well intentioned. Some play a numbers game with the insurance and purposely hand out diagnoses in order to run a shoddy practice where the focus is on quantity of patients rather than quality of care.
So it’s a balancing act, a game of cat and mouse between insurance company and provider. It really shouldn’t be this way but it is, and until something comes along to change it, it’s what we’re stuck with.
So what is Bipolar?
In order to receive a proper diagnosis of bipolar, a patient must fulfill criteria for having had a major depressive episode, as well as a manic episode. Bipolar isn’t just sometimes I’m happy and sometimes I’m sad, like many think. Bipolar is a real, debilitating, organic disorder that is not currently curable.
Due to the organic nature of the disorder, the symptomatology is not in response to anything that is going on in the environment. A bipolar patient’s mood is predominantly due to cycles of the brain. Some are more rapid cycling, at the low end cycling over the course of only a couple days, and some are more lengthy, occurring over several months. Contrary to what some may believe, Bipolar patients do not go through spells of major depression and mania all in the same day. While a bipolar patient can indeed be made happy or sad due to environmental stimuli just like anyone else, it is the baseline mood that we are
interested in for bipolar.
Think of mood as a wave with the high end. In bipolar patients, the wave is much more exaggerated than in people without bipolar, and in fact exceeds what we would call a clinically significant threshold. The goal of therapy in this diagnosis is an attempt to force that wave as close to the middle as possible so that the swings are not nearly as severe and debilitating.
The following is the criteria for Bipolar Disorder. Note that a patient must have qualified for both manic and major depressive episodes at some point.
A) A distinct period of abnormally and persistently elevated, expansive or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary)
B) During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
1) inflated self-esteem or grandiosity
2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
3) more talkative than usual or pressure to keep talking
4) flight of ideas or subjective experience that thoughts are racing
5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
6) increase in goal-directed activity (at work, at school, or sexually) or psychomotor agitation
7) excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
C) The symptoms do not meet criteria for a Mixed Episode
D) The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
E) The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication or other treatment) or a general medical condition (e.g., hyperthyroidism)
Major Depressive Episode
A) Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure
Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations
1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.
2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
4) insomnia or hypersomnia nearly every day
5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
B) The symptoms do not meet criteria for a Mixed Episode
C) The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D) The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism)
E) The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
Note that for each, abusing substances automatically disqualifies you from this diagnosis. If you are abusing substances, your diagnosis is some type Substance Abuse, or Substance Dependence. If you read through these criteria and fail to ring up the proper criteria, you do not qualify. Also, if you feel sad because of something, your diagnosis is from the Adjustment Disorder
spectrum because you are having difficulty adjusting to a stimulus in your environment.
Here is the DSM criteria for ADHD
A. Either (1) or (2):
(1) inattention: six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
(a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
(b) often has difficulty sustaining attention in tasks or play activities
(c) often does not seem to listen when spoken to directly
(d) often does not follow through on instructions and fails to finish school work, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
(e) often has difficulty organizing tasks and activities
(f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
(g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
(h) is often easily distracted by extraneous stimuli
(i) is often forgetful in daily activities
(2) hyperactivity-impulsivity: six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
(a) often fidgets with hands or feet or squirms in seat
(b) often leaves seat in classroom or in other situations in which remaining seated is expected
(c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
(d) often has difficulty playing or engaging in leisure activities quietly
(e) is often "on the go" or often acts as if "driven by a motor"
(f) often talks excessively
(g) often blurts out answers before questions have been completed
(h) often has difficulty awaiting turn
(i) often interrupts or intrudes on others (e.g., butts into conversations or games)
B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).
D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorders, or a Personality Disorder).
Let me draw your attention to a couple things.
First, nowhere in this list you will find it say anything about these types of symptoms only occurring in one venue. So if your child only exhibits ADHD symptoms while at school, and there have been no problems at home, you aren’t looking at ADHD,
but rather, you are looking at our old friend the Adjustment Disorder spectrum.
Secondly, note that it explicitly states that these symptoms should not be caused be oppositional defiance. In other words, if your kid is not paying attention because he’s too busy being bad, then this is not ADHD. Remember ADHD is organic, if a child is acting out because someone or something is upsetting him or her, this is not ADHD.
Third, and most important: for both of these diagnoses it states (in addition to stating this as a requirement for every diagnosable condition in the DSM) that “there must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.” If the kid is making straight A’s, you don’t have ADHD.
So take a look, consider the preponderance of evidence, and make an informed decision about your child’s mental healthcare. If you feel like one of the two above spectrums of disorders is a match for you, your child, or a loved one, Pursuit of Happiness, or any other mental health provider will be more than happy to help ameliorate the symptomatology. But please keep in mind that a proper diagnosis is a cornerstone to proper treatment. Just like you wouldn’t do chemotherapy on someone having a heart attack, it would be wildly inappropriate to treat someone for Bipolar or ADHD who is merely experiencing an Adjustment
Disorder. Our best advice is to choose a provider who will keep their patients best interest at heart, and not voluminously toss around diagnoses without careful consideration of the criteria.
Pursuit of Happiness
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