Thursday, February 16, 2012

Grief/Depression II - Rise in Rates of Mental Illness

Are we really getting sicker?

A New York Times article, When does a broken heart become a diagnosis? sells papers with its usual technique - latch onto a fringe element and substitute good writing skills for substantive analysis.

I am all for good writing skills, and perhaps stumble in the same direction at times.  But depression is my beat.  So God willing and the brain permitting, I am going to beat this bit to the ground.  Two weeks ago I discussed three contexts for the discussion, the cost of health care, the scientific value of the DSM and the hobby horse of the author featured in the Times article.  I promised more contexts to come.

Are We Getting Sicker? - Context IV

James Wakefield's thesis is that we are turning natural human emotions, (the ones we want to get rid of, because they are unpleasant), into a diagnoses.  His beat is depression, as well, but the Times is on this bandwagon with autism and no doubt other diagnoses to come.

Well, I grant some validity to the concern in general.  Is it shyness or Social Anxiety Disorder?  Is it artistic nonconformity or Attention Deficit Hyperactivity Disorder?  Is it the sleep disruptions of normal aging or Overactive Bladder Disorder?  Was it all those wings, doritos and beer you guzzled Superbowl Sunday (and most Sundays), or Gastroesophageal Reflux Disease?


Ever since pharmaceutical companies were granted permission to advertise on television, doctors have been squeezed between patients coming in with new complaints (already armed with the name of a new diagnosis and its pharmaceutical cure) and the sales reps whose visit immediately preceded said patients, carrying samples for the week's latest ailment in their bag.

Maybe we aren't getting sicker.  Maybe we are being sold a bill of goods.

The field of mental health participates in the same phenomenon, though it could be argued that it is a special case.  The ad campaigns for Prozac and everything that came after have made it acceptable to discuss mental illness and to seek treatment for diseases that really did exist before the pills were marketed to alleviate their suffering.

Maybe we aren't getting sicker.  Rather, more of us are finally getting treatment.

The Poor, Pitiful HPA Axis Gets A 21st Century Mugging

On the other hand, maybe we are getting sicker.

I have written about the HPA axis before.  HPA refers to hypothalamus, pituitary gland and amygdala, all in the lizard (earliest to evolve) part of our brain and essential for survival in a hostile world.  Basically, when the snake falls from the tree onto your head, this part of the brain goes into overdrive.  There are feedback mechanisms, so that once the crisis is over, your heart rate goes down, various hormones return to steady-state levels, and so on.  Meanwhile, the incident imprints in the hippocampus, so you remember what sort of tree you were standing under when the snake fell on top of you, and you don't linger there in the future.

So far so good.

However, if your mother insists on putting your cradle under the tree that the snakes fall out of, so the HPA axis gets ramped up several times a day, pretty soon the feedback system goes out of whack.  You remain on high alert at all times.  When you go off to school, your brain is still scanning for snakes, and you can't concentrate on learning to read.  In fact, your brain becomes deficient in the learning-to-read hormone (BDNF), your hippocampus (where BDNF is manufactured) shrinks, and you are set up for a lifetime of vulnerability to snakes and even the sound of rustling leaves, because they remind you of snakes, damn it, and set the whole alarm system off again.

The result: statistically significant increase of risk for every mental illness in the whole damn book.

Some people are more able to shake the snake off than others.  Resilience - such a virtuous word! Doesn't everybody want to be called resilient?  It turns out that particular virtue is not so much virtue as part learned skill and part genetic capacity.

We don't deal with snakes so much anymore.  We deal with...

I counted.  In the course of three weeks, I made three trips by air, entering airports ten times,  counting the plane changes.  Okay, twice the airport was LIR - Liberia, Guanacaste, Costa Rica.  Costa Rica does not set off the HPA axis.  But the others do.  Eight exposures to chronic stress, hours spent with a background soundtrack telling me that a snake is about to fall on my head.  Or rather, a terrorist is about to sneak a bomb into my briefcase.  I MUST BE VIGILANT.

A sum of twenty-four hours, three hours at a time, four different days over three weeks, continuously reminded that federal agents consider my toothpaste to be potentially dangerous, and if I don't keep my mouth shut, I will be arrested.  My body was x-rayed over and over for explosives hidden in orifices.  Meanwhile, I juggled luggage, ran for planes and worried about which particular family crisis awaited me at each destination.  HPA overload.

Welcome to the 21st century.

Given how much air travel your typical presidential candidate does, is it any wonder the fruitcakes we are served up nowadays?  I can't speak for all of them.  But I don't think Mitt Romney used to be such a wacko...

Yes, we ARE getting sicker.  We live in times that make us sick.  We struggle to pay bills while our bosses speed up the assembly line.  Those of us who don't get laid off can't quit, because we can't afford health insurance.  Our support systems, extended family, neighborhoods, religious communities, social organizations - the buffers of stress - have been ripped away, replaced by reality TV and Facebook hysteria.

Not to mention the systematic destruction of the brains of 18-25 year olds who are recruited into the Armed Forces and trained to kill people before their frontal cortexes have developed enough to be able to weigh the consequences.

Our brains were built to handle short-term crisis, not the 24/7 Fox/CNN drumbeat of impending disaster that validate our loss of civil liberties.  Even in what passes for entertainment, CSI et al, the kidnapping of children and dismemberment of young women ramp up the HPA axis, making us vulnerable to the food ads that follow, promising comfort.

What Does Bereavement Have To Do With It?

What difference does it make whether the one damn thing too many is loss of a job or loss of a loved one?  It's still one damn thing too many.  And doctors need to take time to figure out what is going on with the person sitting in the office on her last nerve, not say, There, there. You'll feel better in a couple months.

So dump the bereavement exclusion.

Well, I have tipped my hand, haven't I?

Big Pharma Bonanza - Context V

Having said that, a pill does not solve the problem.  And yes, big pharma has made megabucks selling complaints to patients and solutions to doctors.

Leading their list is Nexium, the top seller in the US, at over $5 billion a year, for Gastroesophageal Reflux Disease (GERD).  Which didn't used to exist.  It used to be, people expected that if they ate too much fatty food at bedtime, they lived with their tummy aches.  The next two top sellers are Lipitor for high cholesterol and Plavix for preventing blood clots after heart attack.

It is so much easier to prescribe a pill than address the patient's eating patterns.

But don't expect Newt Gingrich to address obesity, the #1 American health care issue that is bankrupting government and business alike.  Let's go after the loonies.

Here, too, big pharma worked hard, after Prozac was developed, to educate the American public about the signs of depression and get people into treatment.  Read: on meds.

It was a successful campaign.  One in ten people in the US was on antidepressants in 2005, twice the number of those in 1995.

Mission Creep

Now, not all are taking the meds for depression.  Once big pharma has permission to sell the stuff, whatever the stuff is, doctors can prescribe it for anything, back pain, nerve pain, sleep difficulties, fatigue...  That's how it happens that currently, the best selling psychotropic meds are Abilify and Seroquel -- antipsychotics, for God's sake!  They got a huge market bump when Bristol-Myers Squibb and AstraZeneca respectively convinced doctors to prescribe them to people with treatment-resistant depression.  If you have been on an antidepressant for six weeks or more and still feel depressed, adding ABILIFY could help provide additional symptom relief, they tell you over at abilify.com.  Be sure you read the part about how it could also give you facial tics for the rest of your life (even after you stop taking it) and cause diabetes, a condition much more likely to kill you than some residual blues.

Over-medicated, Not Over-diagnosed

The clinical evidence is that aerobic exercise and cognitive behavioral therapy are much more effective than Abilify or Seroquel to deal with residual feelings of depression.

The clinical evidence is that aerobic exercise and cognitive therapy are just as good as antidepressants to handle mild or moderate depression in the first place.

And, by the way, the side effects of aerobic exercise and cognitive behavioral therapy will not kill you, nor cause physical conditions such as obesity, heart disease and metabolic conditions that will kill you, like your medications.

Remember: weigh your costs and benefits.  For some people with mental illness, the risk of earlier death is a bonus, compared to the prospect of living those extra years with the ravages of the illness.

Over-medication and Bereavement

For those not fluent in DSM-speak, let me bring you back round to the point of debate.

The DSM, the dictionary of diagnoses, lists a bunch of symptoms for depression.  They are experiences common to all of us.  To receive the diagnosis, one has to have a certain number of them every day for most of the day for two weeks.

Unless somebody important to the patient has died within the last two months.  People in grief are not diagnosed with depression, because the symptoms of depression are natural to the grieving process.  That is the Bereavement Exclusion.

The proposed DSM V would eliminate the exclusion.  James Wakefield and others are concerned that this move would mean that people who experience normal grief would receive unnecessary medication, with the risk of side effects, and the stigma of a mental illness.

Now, over in dermatology, upon seeing a suspicious spot, my doc doesn't decide to wait for two months, for fear of saddling me with the stigma of cancer.  But I digress.

I want to suggest a different hobby horse for Wakefield, or rather, a return to his own book, which would serve a whole lot more patients a whole lot better -- that doctors ignore the stigma issue and instead, listen longer before prescribing these medications to anybody.

Some appropriate questions for good prescribing practice include: How severe are these symptoms?  Did you have these or other symptoms before your loss, and if so, for how long?  Have you had other times in your life when you felt like this?  And, by the way, have you had times in your life when you felt on top of the world, able to accomplish amazing amounts of work?  Or times of extreme anxiety?  And how would those who know you well answer those last two questions?

Better yet, the doctor should ask the patient's friends and family directly, because a depressed person does not remember feeling better, and will not be able to identify manic or hypomanic symptoms which are contra-indications for antidepressants.

Bereavement might be a coincidence.  It might come in the midst of an ongoing illness.  It might set off a pre-existing vulnerability.  It might spark a relapse.  Widows deserve medical care that pays more attention to these questions than the calendar.

In any case, if somebody isn't a danger to him/herself or others, and is able to take care of him/herself, the appropriate prescription might be (OMG!) therapy, exercise, friends, pets, sleep (maybe medically assisted), a grief support group, attention to diet.

Conclusion Coming Soon

Ronald Pies and Sidney Zisook, the original proposers of the change opposed by Wakefield, deserve their own time to weigh in.  Dr. Pies addressed the issue briefly in a comment to my first post on the DSM proposed revisions of the section on mood disorders.  I will expand on the research that led them to propose the change.

I think I will also do a riff on my own recent experiences of grief and depression.  Why not.  I am my own lab rat...


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

Grief? Depression? Both? January 28, 2012 -- The contexts of DSM revision debate over the Bereavement Exclusion: health care costs, the DSM and the inadequacy of symptom silos, the mind/brain debate, poor health care for the bereaved.
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.com
image of cash register from Microsoft clip art
photo of airport security in public domain
photo of Harold Lloyd, Safety Last, in public domain
photo of woman on bicyle by pedrosimoes7 and used under the Creative Commons Attribution 2.0 Generic license

4 comments:

  1. Hi, Ms. Goodfellow--

    Thanks for inviting me to comment on the contentious issue of the bereavement exclusion (BE). As you well know, Dr. Zisook and I have written a number of pieces on why we favor removal of the BE from the DSM-IV--it seems you agree, so I feel I am in good company!

    Our group will have a long paper coming out in the journal Anxiety & Depression, in which we analyze dozens of studies, and still reach the conclusion that most of the evidence does not support the BE. The few studies that do support it are based on national survey data, rather than on studies of actual depressed patients.

    Unfortunately, the lay press has really botched the issue, and miscommunicated what the DSM-5 work group is proposing. Even the print edition of the NY Times (Ben Carey's article) led with the headline, "Grief Could Join List of Disorders”--which is balderdash!

    The press keeps telling people that the DSM-5 wants to set a 2 week limit on "grief." That's nonsense. All they are really saying is that if "it looks like a duck, walks like a duck, and quacks like a duck, it's likely to be a duck, until proved otherwise!" That is: if a patient shows up in the doctor's office meeting the full symptom and duration criteria for Major Depressive Disorder(MDD); but happens to have lost a loved one within the past two months, we should not withhold the diagnosis of MDD, simply because it occurs in the context of bereavement.

    Zisook and I also believe that the original studies by Dr. Paula Clayton--which formed the basis for the BE in DSM-III and IV--were
    never sufficient to validate the BE, which should never have entered the DSMs in the first place.

    All that said: both Dr. Zisook and I believe, on the basis of our clinical experience, that the 2-week minimum duration criterion for MDD is too short to permit confident diagnosis, after bereavement. We would much prefer to wait at least 3 or 4 weeks after a major loss before diagnosing MDD, except in certain severe cases (e.g., patient is suicidal or has melancholic features, has previous MDD episodes). In the real world, however, very few depressed patients come in to the doctor's office just two weeks after a major loss. When a bereaved person comes in meeting all the symptom and duration criteria for MDD, within 2 months of the death, we find no credible basis for withholding a diagnosis of MDD...it's the "duck" argument again!

    Many critics think this will mean over-use of antidepressants. But we believe that this is a matter to be dealt with through intensive medical education--especially of primary care doctors--and should not be dealt with by jiggering with our diagnostic criteria. Indeed, mild-to-moderate MDD should be treated, first, with "talk therapy", not antidepressants, in my view; I would reserve medication for more severe and/or melancholic cases.

    I also believe we need to educate all doctors as to the nature of grief, as distinct from depression; and that the DSMs do a pretty bad job of that. You can find more on this in my posting on the Psychcentral website, entitled, "The Two Worlds of Grief and Depression." There, I try to depict the "inner world" of the grieving person, in contrast to that of the clinically depressed individual.

    I appreciate your interest in this controversy, and I hope these comments are helpful to your readers.

    Best regards,
    Ronald Pies MD

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  2. http://psychcentral.com/blog/archives/2012/02/28/how-the-public-is-being-misinformed-about-grief/

    Hi, Willa--I thought you and your readers might want to see this recently posted blog, on the Psychcentral website.

    ---Best, Ron Pies MD

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  3. I stumbled across this blog trying to find out the depression rates in CR, but as a therapist I'm very interested! How come you were in Liberia? I'm in Tamarindo for a week because my husband's dads have a condo here.

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  4. To read more about me in Costa Rica, move your curser over to the Labels section in the right-hand column of the blog and click on "Costa Rica." The earliest post (9/09) reflects on depression in Costa Rica -- sorry, no stats. Along the way you will find a youtube that tells how it all began...

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