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296.89, bipolar, bipolar ii, classification, diagnosis, diagnostic codes, disease, DSM, DSM-IV, dx, F31.81, ICD, ICD-10
Diagnostic codes are a way of categorizing illness and putting us into nice neat little pigeonholes. There’s a brilliant discussion of how classification of disease changes perceptions and management of illness in one of my favorite academicky books, “Sorting Things Out: Classification and Its Consequences.” If you have a penchant for highbrow nonfiction reading, I highly recommend it. The analysis in that book essentially underscores much of what I’m going to say here, but is way smarter.
There are two major mental health classification systems. That’s not 100% accurate, because the ICD-10 (International Statistical Classification of Diseases and Related Health Problems, version 10) actually covers every disease everywhere. Or at least it attempts to. The DSM is the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychological Association, and used primarily in the US and to some extent internationally across related industries. The current version is the DSM-IV-TR (fourth edition, text revision.) The DSM-V is due out in 2013, and is currently causing a massive amount of debate in the US mental health system.
Diagnostic codes shape the way we’re treated. I’m going to be a bit scathing about them, but it’s important to recall that they serve a real, valid purpose, so just remember – I did admit that there’s a reason for them. These all-important diagnostic codes are the professionals’ way of reducing a massively complex mental condition into something comprehensible when they see 10-30 people a day. My therapist’s paperback copy of the DSM is so worn that pages fall out and it’s held together with rubber bands.
The diagnostic code that goes on my paperwork: 296.89. If I were seeking services in Europe, it turns into F31.81. Confused yet?
A quick search will show you what each of these codes means. F31.81: Bipolar II Disorder. The entirety of the definition for Bipolar disorders in the ICD is described by one sentence and three short bulleted lists. It’s paired up with descriptions of the mood states, but those diagnostic criteria are pretty terse, too. It hardly does credit to the complexity of this kind of crazy. The “F” subset of ICD codes is for “Mental, Behavioral and Neurodevelopmental disorders” and the F30′s are for “Mood [affective] disorders”, with F31 specifying Bipolar disorder.
The subsets of F31 are a complicated list of every possible state of bipolar that the clinicians could concoct, describing whether the condition is in remission, what kind of episode you last had, etc. Oddly, F31.8 is “other bipolar disorders” and includes just Bipolar II and Other bipolar disorders, while the F31.7 category, Bipolar Disorder Currently In Remission, has 9 subcategories. Out of almost 30 potential classifications of bipolar, there’s only one for Bipolar II! What does this tell you about what the medical establishment really knows about Bipolar II? Not much, it would seem. I won’t even get started on the diagnostic criteria themselves.
The DSM has a somewhat different set of criteria and is more specific about discriminating between Bipolar I and Bipolar II, although its criteria are still questionable and undergoing revision for v5.0. Like the ICD, the DSM includes multiple flavors of Bipolar I, but just one type of Bipolar II, 296.89 (with some optional modifiers.) I’m not going to recite the diagnostic criteria because they’re easy to find online. If you dig into definitions, it actually specifies how many days make up a hypomanic versus manic episode. Really? That’s a defining feature? I’m not sure what value the medical professionals find in having 20+ types of Bipolar I (but only one type of Bipolar II.) In practice, the division between these diagnoses is neither precise nor consistent.
A diagnostic code has a lot to do with the treatments that are provided and whether insurance will pay for them. After my first therapy appointment with Hippie Dude, he remarked that the bipolar diagnosis was one that the insurance will pay for. Presumably that’s in contrast to other psychiatric conditions for which insurance would not cover therapy? Diagnostic codes are also expected to align with treatment, so the fact that I’ve got a 296.x dx means that my insurance will pay for a whole lot of pills and a whole lot of therapy. It also means that I had better not go uninsured at any point in my life, or it turns into a very expensive “pre-existing condition” – also known as “uninsurable.”
And then there’s the prognosis. It just isn’t so good for any bipolar dx. The outcomes are better with proper treatment, which results from proper diagnosis, but it takes up to 10 years for most people with Bipolar II to get the right diagnosis (um, try 15?) which is usually preceded by one or more incorrect diagnoses and treatments that can actually worsen the condition. Some people do improve. But overall, bipolar disorder is associated with a very high suicide rate (10% – 20%) and a life expectancy 12-13 years shorter than average. Not cool. Presumably, the high mortality rates for all natural causes of death have to do with the toll that mania and depression take on the body, and the bad health habits that often form in response to mood swings. At least that’s something we can attempt address with healthier lifestyle choices.
Update: Bizarre stuff in the ICD-10 – “Other contact with dolphin”
Interesting post!
Ten years from my first diagnosis. You’d think that doctors would be aware that if MDD is not responding to treatment within a certain period of time, then it would be time to consider BP II. But, no. Doctors are eager to treat MDD because it’s pretty straightforward. SSRI’s and you’re out the door.
Five years of treatment with no success. I had to give up, because I honestly didn’t think anyone could “fix” this. And that’s awful. It removes faith and trust in the psychiatric community. I could only be convinced to seek treatment after my son was born for the sake of my family. Think of how many others that continue to suffer in silence.
20 years from initial MDD dx, and 15 from manic symptoms. But I think originally MDD was probably accurate.
I was lucky (?) enough that they tried an SNRI and then an NDRI after the SSRI’s didn’t work and caused frightening side effects. The NDRI actually took enough of the edge off the depression to get by for a long time, and I just never reported other symptoms after having them blown off early on.
After having useless “treatment” by the psych community, I definitely had no trust in them. Made it really, really hard to stick out the year-long process that finally lead to diagnosis and treatment.
I quit treatment for MDD at a very tender time. I developed alcoholism in the meantime. I can attribute all of my successes with detox and seeking psychiatric help to both my husband and my son. My husband stopped me from drinking. I got pregnant with my son and couldn’t drink anymore at all. When he was born, I was hit like a ton of bricks with symptoms. Clear cut symptoms emerged that were not as present since I was a teen.
When I was a teen, I didn’t have access to the same substances I used to self-medicate as an adult. So, it became less evident that I was sick.
Those were the best unintentional measures of intervention that ever happened to me. It’s sad that I had to suffer and remit so many years to substance abuse. But, I didn’t have to go through this my entire life. Under any other circumstance, I would have likely continued on that awful course until I was dead. My family saved my life, not any psychiatrist.
Excellent post, DeeDee. It’s pretty aggravating to find oneself boiled down to an alpha numeric code. Especially when it’s the wrong one, which like you say happens to most of us before we arrive at the right address.
A note on insurance: there is now health insurance for us actually sick people. It’s called Inclusive Health. There is a “federal option” and a “state option.” Federal is better because the states are forever changing their minds about it. You have to qualify for it by having an illness that is on their list. Bipolar is on it. You also have to show that you have been rejected by another carrier, or subject to significant restrictions/ exclusions or unreasonably high premiums. For me that was easy because Blue Cross first outright rejected me, then made me the generous offer of insuring me for $1400 a month, excluding care for anything Bipolar related. Inclusive Health costs me $550 a month with a $1000 deductible, still expensive but doable.
Regarding life insurance: it is to laugh! No way. So if you currently have life insurance, hold onto it for dear life.
Good to know! I currently have life insurance through my husband’s employer, but when employment situations change, who knows what will happen? I am supposed to get life insurance through my next job, but again, who knows?
I’m planning on moving to my husband’s health care at the next “qualifying event” and I don’t know if they can turn me down under those circumstances. I guess I can always be unpleasantly surprised… COBRA would be cheaper than most of those other options, but still. This stuff is getting so complicated!
Bipolar I Disorder, Most Recent Episode Manic, With Psychotic Features. . . Who cares? But I am very fortunate (and apparently a major exception) because my psychiatrists have always looked past the diagnosis, at the person.
Doctors do have to have some sort of system for sorting out these complexities, and it’s a relatively new idea. So the practicing part of medicine really comes into play.
No one has even bothered to get that specific with my diagnosis, which sort of irritates me. It says a lot about the quality of care I’ve had.
If we were going to get technical about it, though, it would be Bipolar II with atypical features, seasonal pattern, and rapid cycling. Woohoo, lucky me! I don’t need a psychiatrist to tell me about those details, since I’ve seen a lot of evidence for those modifiers. But it would be nice if they even tried.
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