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.