1 Boring Old Man ? speaking of persistence?

I had a long and complicated look at Major Depressive Disorder, the Bereavement Exclusion, and the proposal to remove it in the DSM-5 a few days ago [the what is absurd?]. I realized how angry I am that they want to take out the Bereavement Exclusion yet neglect their real task ? revising the whole category [MDD]. I proposed [along with many before me] that MDD itself is a remnant of a political negotiation from long ago rather than a real psychiatric disorder. Adding Grief into the already overcrowded MDD neighborhood seems insulting to patients and colleagues, over and above being irrational. It is so predictably an open invitation for overmedication that their motives and logic don?t even really matter. Even if they actually believe the forced logic that grieving people with profound symptoms won?t get necessary treatment [eg antidepressants], they should be able to see that risk/benefit considerations are prohibitive. Add to that ? nobody wants them to do this other than a few people on the DSM-5 Mood Disorders Work Group. I was actually glad to see that Dr. Frances retains a level-headed approach to the problem:

Psychology Today: DSM5 in Distress
by Allen Frances, M.D.
January 3, 2013

^{In my list of the 10 worst things about DSM 5, its decision to confuse normal grief with clinical depression earned a very high ranking at second place. DSM 5 will go to press at the end of January. The American Psychiatric Association has just four more weeks to reverse this dreadful mistake that flies in the face of clinical common sense and is unsupported by the limited available science.}

^{The DSM 5 medicalization of grief has been opposed by editorials and scientific papers in the major medical and psychiatric journals, by hundreds of newspapers articles, and by the 200,000 grievers who viewed a moving blog by Joanne Cacciatore that went viral. So far, APA has lived in its cocoon ? stubbornly sticking to its senseless decision, oblivious to the intense opposition both from the experts in the field and from the many people it will mislabel. Making grief a mental disorder will be a bonanza for drug companies, but a disaster for grievers.}

^{The decision is also self destructive for DSM 5 and further undermines the credibility of APA. Psychiatry should not be mislabeling the normal. Instead, our field should focus attention on getting more resources for the treatment of patients with clear and severe mental disorders- those who are now receiving far too little care as mental health budgets are slashed. This final plea to reason comes from the three people who have been most active in protecting grief from being mislabeled as mental illness.}

Dr. Frances reports on the thoughts of three people with hard-won expertise in the treatment of the bereaved:

^{The first is Joanne Cacciatore ? psychologist, researcher, clinician , bereaved parent, and founder of the MISS Foundation and Center for Loss & Trauma?:}

^{"It is simply outrageous that DSM 5 will diagnosis mental disorder in the normally bereaved as early as two weeks following their loss- thus encouraging the massive misdiagnosis of grief as Major Depressive Disorder. Under trained primary care doctors are particularly likely to confuse grief and depression and to over treat with psychotropic medication. Drugs are necessary for the severe symptoms of depression in some individuals, but there is no evidence they are good for expectable grief. In fact, the research shows that the bereaved are already being medicated earlier than can be justified." "We issue an ardent appeal to DSM 5. Please, do not medicalize normal grief. It is not at all pathological to have symptoms that closely resemble mild depression during bereavement. The Bereavement Exclusion is absolutely necessary to protect against the false positive over diagnosis of depression. Keep it in place. The bereaved are already vulnerable. So, please take to heart your responsibility to them- ?first do no harm?."}

^{The second email is from Russell Friedman: co-founder of The Grief Recovery Institute Educational Foundation and co-author of ?The Grief Recovery Handbook? and ?When Children Grieve?:}

^{"One of the very few defenders of the indefensible DSM 5 decision to pathologize grief is quoted as saying : ?Well-trained clinicians will be able to make this distinction [between normal grief and depression] and most have done so without the help of DSM-5 for many years.?"}

^{"This is far too optimistic an appraisal ? true only for the distinction between grief and severe depression. Not even the best trained clinicians can distinguish grief from mild depression. And a totally untrained and ill-equipped GP, in his 6-8 minute consultation with the new widow or widower, might as well be blindfolded and throw darts at targets marked MDE or Normal Grief, while prescribing unnecessary meds that will bury the griever?s feelings- where they will likely fester. In its zealous attempt never to miss any possible patient, DSM 5 endorses further loosening of what are already too loose criteria for depression ? thus mislabeling grief and potentially hurting many millions of grievers."}

^{The third email is Jerry Wakefield, Professor Of Social Work and Psychiatry at New York University:}

^{"DSM 5 claims that its decision to relabel mild depressive feelings during grief as clinical depression was based on scientific evidence. This is simply not true. In fact, the evidence goes strongly against the decision. For example, two critical features of clinical depression are that it predicts a higher likelihood of later recurrence of new depressive episodes and a highly elevated rate of suicide attempts. Studies show that the depressive feelings during grief that the DSM 5 is going to relabel clinical depression do not predict higher rates of either of these problems.}

^{"The scientific literature documents that on many other important measures as well, such grief is unlike clinical depression and more like intense normal emotions that improve on their own with time. Similar normal feelings of sadness occur in reactions to other losses, such as marital dissolution, romantic betrayal, job loss, financial trouble, natural disaster, and a terrible medical diagnosis. Such reactions are currently diagnosed as psychiatric disorders when in fact studies show they too are often normal responses. The evidence indicates that DSM 5 should be narrowing the category of clinical depression, not broadening it."}

^{"Grieving individuals need and deserve support and frequently consult general physicians seeking help with sleep or other symptoms. The provision of such help should not be distorted by a spurious medical diagnosis that is not supported by the scientific evidence."}

And then adds his own commentary:

^{Many thanks to all three correspondents for this and for their previous efforts to save DSM 5 from itself. The need to preserve Freud?s valuable distinction between ?Mourning" and "Melancholia? seems self evident to everyone except the people responsible for DSM 5. There was no previous problem in DSM IV that needed fixing. Grievers who have severe and urgent symptoms- suicide risk, psychotic symptoms, severe agitation. Inability to function- have always qualified for the diagnosis of Major Depressive Disorder; while those having typical symptoms of grief were appropriately regarded as having a normal, human reaction to a grave loss. As Dr Wakefield points out, the criteria for mild forms of Major Depressive Disorder are already too loose when people are experiencing any kind of loss ? DSM 5 now makes the strange choice of making them looser.}

^{After 40 years and lots of clinical experience, I can?t distinguish at two weeks between the symptoms of normal grief and the symptoms of mild depression ? and I challenge anyone else to do so. This is an inherently unreliable distinction. And I know damn well that primary care doctors can?t do it in a 7 minute visit. This should have been the most crucial point in DSM 5 decision making because primary care docs prescribe 80% of all antidepressants and will be most likely to misuse the DSM 5 in mislabeling grievers. Drug companies will probably jump at this golden opportunity to mount a disease awareness ?educational campaign? spreading the false DSM 5 gospel that depression can be reliably diagnosed among normal grievers. And the instinct of primary care docs is always to reach for their prescription pads or the free samples on the shelf as the quickest way to get the griever out of the office. Grief is a normal and inescapable part of the human condition, not to be confused with psychiatric illness. Let us respect the dignity of mourning and treat it medically only when it becomes melancholia.}

^{APA needs to reconsider a really bad decision that will seriously reduce its credibility and encourage the DSM 5 boycott I am told is now in its planning stages.}

When I looked at the articles by the Mood Disorder Work Group authors a few days ago [the what is absurd?], the ten year old article using Wellbutrin to treat grief struck me:

^{OBJECTIVE: The present study was conducted to assess whether DSM-IV-defined bereavement responds to bupropion sustained release [SR].}

^{METHOD: Twenty-two subjects who had lost their spouses within the previous 6 to 8 weeks and who met DSM-IV symptomatic/functional criteria for a major depressive episode were evaluated. Subjects completed the Hamilton Rating Scale for Depression [HAM-D], the Clinical Global Impressions scale, the Texas Revised Inventory of Grief, and the Inventory of Complicated Grief at baseline and follow-up. Subjects were treated with bupropion SR, 150 to 300 mg/day, for 8 weeks.}

^{RESULTS: Improvement was noted in both depression and grief intensity. For the intent-to-treat group. 59% experienced a reduction of > 50% on HAM-D scores. The correlations between changes in the HAM-D scores and the grief scale scores were high, ranging from 0.61 [p = .006] to 0.44 [p = .054].}

^{CONCLUSION: Major depressive symptoms occurring shortly after the loss of a loved one [i.e., bereavement] appear to respond to bupropion SR. Treatment of these symptoms does not intensify grief; rather, improvement in depression is associated with decreases in grief intensity. The results of this study challenge prevailing clinical wisdom that DSM-IV-defined bereavement should not be treated. Larger, placebo-controlled studies are indicated.}

That study had no control group so it really shouldn?t even be in the mix, but there was something else, "Twenty-two subjects who had lost their spouses within the previous 6 to 8 weeks and who met DSM-IV symptomatic/functional criteria for a major depressive episode were evaluated." Even they waited a considerably greater time than they?re suggesting in their appeasment plans for the DSM-5.

Another thing that I thought as I read through all those articles was:

^{"The fact that they interpreted their results as meaning the Bereavement Exclusion needs to be abolished is a telling, and very discouraging. To me it means that they have come to see the DSM-III, DSM-IV, and now DSM-5 definition of Major Depressive Disorder as a sacrosanct entity unto itself rather that just a list made at some point in history for reasons having to do with an anachronistic political squabble within psychiatry. They?ve confused the signifier with the signified?"}

I still feel surprised that they can be this far off the mark and apparently not know it. They?re missing the boat about Grief, plain and simple. They?re off the mark about the motives of Dr. Frances who is trying his best to keep them from jumping into the deep end of the pool without knowing how to swim. And they?re assuming a right to make an arbitrary and counter-intuitive change with neither scientific evidence nor credible argument. If they persist and send the DSM-5 to the printer with the Bereavement Exclusion removed, they are as much as admitting that it is no longer the Diagnostic and Statistical Manual of Mental Disorders. It?s something else, maybe a Manual of Psychiatric Opinion ? APA style, and they?d best make a drastic cut in the number of copies they order, because they are claiming an authority that they haven?t earned. They?ve spent a lot of time and money on this revision, and they?re about to throw it all away for no apparent reason. The vote is in and counted?

Source: http://1boringoldman.com/index.php/2013/01/04/speaking-of-persistence/

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