Saturday, January 28, 2012

Grief? Depression? Both?

The New York Times reports this week on a proposed change to the definition of depression for the Diagnostic and Statistical Manual (DSM) V.  Asking, When does a broken heart become a diagnosis? it raises the specter that normal grief at the death of a loved one could be classified as a psychiatric disorder.

An estimated 8 to 10 million people lose a loved one every year, and something like a third to a half of them suffer depressive symptoms for up to month afterward, said Dr. Jerome Wakefield, author of The Loss of Sadness.  This would pathologize them for behavior previously thought to be normal.

Okay, before we get our knickers in a twist -- oops, too late.  Knickers in a twist is the current US national pastime.  Nevertheless, there is a larger context here.  Several, in fact.

DSM Context I - Follow The Money

The new publication deadline for the DSM V is December, 2012.  You can expect the volume of criticism to rise.  The New York Times health reporting department will not have to come up with an original idea for the next 11 months.

First is the push/pull over including more diagnoses and loosening criteria so that more people receive diagnosis, followed by a storm of criticism that has led to tightening criteria to exclude people from diagnosis.

The thing is, if you don't get diagnosed, you don't get treated.

How do we deal with the explosion of PTSD cases?  DSM V decides, let's limit the definition of trauma to rape and violence with the expectation of death (as determined by an outside observer, not by the expectation of the person who experienced or witnessed it).  How about so many autism diagnoses?  Again, change the definition so you don't qualify if you can dress yourself.  (I may write more about that one later...)

I had an epiphany the other day.  We could save billions in health care costs in the US.  Right now if you have a blood pressure reading of 140-159/90-99, you have hypertension.  You should lose weight (hah!) or talk to your doctor about medication.  If it's 160/100 or above, you are in deep doodoo and your doctor is liable for lawsuit unless you start taking Lipitor immediately.  Lipitor has the second highest sales in the US, bringing in over $5,000,000,000 for Pfizer every year.


So change the scale!  If we decide hypertension begins at 150/100 and you don't have to be concerned about the stigma of a diagnosis, carrying with it difficulty getting a job with your high health care costs until you get to 170/110, we get a massive overnight reduction in the hypertension levels of the US, and billions of savings in the cost of drugs.

Enter the requirement that health insurance cover diseases of the brain the same way it covers diseases of the heart, and we have big pressure for the shrinks to shrink the DSM.

DSM Context II - Can't We Just Drown This Puppy?

Meanwhile, science has overtaken the DSM.  The DSM answers questions that scientists don't ask.  It gives names to lists of symptoms, manifestations of disease.  The DSM debate is all about how many symptoms to put in a silo to which we give this particular reimbursement code?


Scientists don't ask, how many?  They ask why?  And the thing about depression is, we don't know.  Or rather, when this particular person is sitting in the doctor's office with one symptom from depression's Column A, four from Column B, we don't know why he/she has these symptoms.

There are lots of ideas.  Lots.  The truth is, for you it's one thing, for your neighbor, probably something else.  For your neighbor's brother, probably the same as your neighbor.

For the widow who isn't getting over it, maybe it's normal grief, and she will get over it in time.  On the other hand, maybe she's got what you've got, and has had it for months already, but the anxiety about her husband's medical bills disguised the symptoms.


This is why, if your antidepressant works for you, you are just plain lucky.  It happens to treat the problem in your particular brain.  Most of the time, it treats somebody else's problem.

But it's all called depression.

We actually have the tools to figure out depression, the tools that scientists use to study the brain, not the amateur chemistry set that you and your doctor are playing with.  We just don't have the money for the research.  Nor the political will to raise the money.

But if ever we do, and for schizophrenia, as well, then you won't be able to give away your DSM, whether version IV, IV-TR, or V, for the price of shipping at Amazon.  Because your doctor will treat the cause of your problem, not this sad sorry list of symptoms that could be all sorts of things.

Mind/Brain Debate Context III

The 1968 version of the DSM (II) distinguished between depressions caused by something gone haywire in the brain and those caused by an external event.  Like, is it a chemical imbalance (endogenous, from the inside), or did your boyfriend just break up with you (exogenous, from the outside)?


Dr. Wakefield, featured in the Times article, thinks we need to make this distinction, which is the thesis of his book.  Sadness is a natural human emotion in response to all sorts of things, and we shouldn't try to medicate it away.

Well, that boat sailed without him some time ago.  It turns out that your boyfriend breaking up with you changes the chemistry of your brain.  What happens in the mind manifests physically; what happens in the brain manifests mentally.  Doctors can't tell whether the breakup triggered a disease that lay dormant, or it tipped the capacity of your resilience, such that this time you can't get over it, or it's simply a coincidence.  For that matter, maybe you got dumped because you were already sick and your boyfriend thought you were becoming a downer.

So they decided to focus on the evidence in front of them, asking What is going on now?  How many symptoms indicating depression does this person have; for how long; and how severe?  Whatever made this person unhappy, if it has gone on this long already, does he/she need help to get over it?

The Bereavement Exclusion is the only remnant of exogenous depression in the DSM.  Well, there is adjustment disorder, which is a whole other mess for some other day.  I am talking about depression.  You can get cancer and lose your house because you chose your chemo over your mortgage.  You can work your whole life for a company whose suits ran off with your pension plan and you have to go back to work at age 72.  Your daughter can become Newt Gingrich's next personal assistant.  You can get treatment for the depressions that follows any of these events, if you have the requisite five symptoms and two weeks.  Dr. Wakefield doesn't think you should, but like I said, that boat has sailed.  He is trying to hang onto the one exception, that somebody died.

Remember Bereavement? - Context IV

There is more: poor diagnostic skills, limited range of imagination in the area of treatment, what the people who proposed eliminating the bereavement exclusion have to say, what those little old ladies who never got treatment are like twelve years down the line, maybe even some personal reflections on the difference between depression and bereavement from one who has a lot of experience of the former and current experience of the latter...

One symptom of depression common to bereavement is fatigue.  So I will quit for now and hope to get back to you soon...

Note added 01/02/13 -- Other links in this series are listed below:

Grief/Depression II -- Rise in Rates of Mental Illness February 16, 2012 -- More context: sress and big pharma.  This post begins my correspondence with Dr. Sidney Pies.
Grief/Depression III -- Telling the Difference February 23, 2012 (my mother's birthday) -- Autobiographic take on the subject, how I could tell when I was experiencing grief and when depression.  This post entered the debate, got excerpted and passed around among the big guns who worked out the final resolution!
Grief/Depression IV -- Not the Same/Maybe Both March 1, 2012 -- Biomarkers for depression and grief.
flair from Facebook
photo of Chinese menu by Hoicelatina, used under the Creative Commons license
photo of pair of dice by Roland Scheichder, in public domain
book jacket from Amazon.com

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