Defining Grief

Submitted by: Mike Spindell, Guest Blogger

 The bible of psychiatric/psychological diagnosis is the “Diagnostic and Statistical Manual of Mental Disorders (DSM)” published by the American Psychiatric Association. What it does is provide a standardization of diagnostic criteria, which allows Mental Health professionals to communicate with one another in a clearly defined set of common understandings.

 “It is used in the United States of America and in varying degrees around the world, by clinicians, researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies, and policy makers. The DSM is a legitimating document and provides legal, medical, and ethical justification for physicians to diagnose and treat, judges to incarcerate and excuse, insurance companies to pay.”

First published in 1952 the DSM has undergone five revisions since then. The latest revision will be the DSM V, scheduled for a May 2013 publication. The last major revision in 1994 was called naturally the DSM IV. There are many problems with the DSM.  Since this Manual is so important to the treatment for those suffering and recompense for those who profit from psychiatric/psychological needs, this is an issue that needs greater public awareness. I think is most pertinent to look at the underlying issues entailed in the DSM’s new iteration and how it affects us, or those we know. To do so, however, we must look at the problems with the DSM, from a psychological, systemic and economic perspective.

The first critical issue is that no health insurance company, Medicare and/or Medicaid will pay for psychological and/or psychiatric treatment and medication, without a professionally certified diagnostician categorizing the patient with a valid DSM diagnostic code. Thus the DSM’s definitions have critical importance to practitioners, provider agencies, drug companies and health insurance providers. I retired from the Mental Health profession seven years ago and other things have held my interest. However, l I caught a NY Times article, posted at the MSNBC website last week and it brought to mind issues that had bothered me during my career, specifically with the DSM.

The NY Times article titled: “Grief Could Join List of Disorders” was by Benedict Carey. Its title refers to an ongoing controversy about adding grief (in the case of the death of a loved one for instance) as a category of Depressive Disorder. The word has gotten around the psychological community about this change and the result has been a back and forth of angry claims by professionals on both sides of the issue.

On one hand:

“In a bitter skirmish over the definition of depression, a new report contends that a proposed change to the diagnosis would characterize grieving as a disorder and greatly increase the number of people treated for it. The new report, by psychiatric researchers from Columbia and New York Universities, argues that the current definition of depression — which excludes bereavement, the usual grieving after the loss of a loved one — is far more accurate. If the “bereavement exclusion” is eliminated, they say, “there is the potential for considerable false-positive diagnosis and unnecessary treatment of grief-stricken persons.” Drugs for depression can have side effects, including low sex drive and sleeping problems.”

That represents the side of this issue that believes the definitions of clinical depression should remain the same and feels adding grief to it will have far more negative than positive effects. There is the other side of course which thus far seems to be prevailing and:

“… experts who support the new definition say sometimes grieving people need help. “Depression can and does occur in the wake of bereavement, it can be severe and debilitating, and calling it by any other name is doing a disservice to people who may require more careful attention,” said Dr. Sidney Zisook, a psychiatrist at the University of California, San Diego.”

With a little research into Dr. Zisook I found this piece of information in a article called “Bupropion Sustained Release for Bereavement: Results of an Open Trial” by Dr. Zisook:

“Financial disclosure: Dr. Zisook is a consultant for Glaxo Wellcome, SmithKline Beecham Pharmaceuticals, Pfizer Inc, and Novartis Pharmaceuticals Corporation; has received grant/research support from Bristol-Myers Squibb Company; has received honoraria from Wyeth-Ayerst Laboratories, Eli Lilly and Company, and Forest Pharmaceuticals, Inc.; and is on the speakers bureau for Glaxo Wellcome and SmithKline Beecham Pharmaceuticals.” 

With my own full disclosure let me state that I know nothing of Dr. Zisook’s work other then what I am quoting above. He may well be a wonderful clinician admired by all and other than these quotes; I have no knowledge of his behavior. However, when I see any researcher, whose research is sponsored by drug companies and is on their speaker’s bureau, I must admit that my suspicions are aroused. The final six years of my career were spent creating and running programs for people with severe mental disorders, who were co-diagnosed as drug addicts. I saw the unnecessary use of psychiatric drugs as much as I saw their benefits. Too often the drugs were palliatives that avoided treatment and hamstrung the patients with noxious side effects from ever changing experimental cocktails. I have also seen wondrous breakthroughs in patients via use of medication, but not enough to convince me that they were completely the salvation of my profession.

To put it bluntly, I am appalled at the attempt to turn grief into a psychiatric disorder, even as I am aware from my own personal experience how devastating grief can be. In my own life I was engaged in a prolonged grieving for my parents, who died when I was on the cusp of manhood. To me, to be human is to have to come to terms with grief in one’s life. We are mortal beings. Illness, disease, violence and accidents strike us all with many dying far before their time. Our organisms have evolved internal mechanisms to deal with grief, simply because it is unavoidable. Turning a normal human experience into a Mental Disorder seems to me to be the work of people who have seen much, but yet understood little. It also can be the development of a new cohort of consumers of psychiatric pharmacology, a profit center if you will. Is it cynical of me to wonder if the estimable Dr. Zisook is perhaps unconsciously motivated by his own self-interest? I don’t doubt that he sincerely believes in the medications he peddles, but I wonder if that belief is unconsciously informed by the need to remain in the good graces of his benefactors. The NY Times article shows that I am not a lone voice howling to the wind, but actually a latecomer to this debate, a minor player only by dint of this blog:

“Many doctors and therapists approve of efforts to eliminate vague, catch-all diagnostic labels like “eating disorder-not otherwise specified” and “pervasive development disorder-not otherwise specified,” which is related to autism. But a swarm of critics, including two psychiatrists who oversaw revisions of earlier editions, has descended on many other proposals.

“What I worry about most is that the revisions will medicalize normality and that millions of people will get psychiatric labels unnecessarily,” said Dr. Allen Frances, who was chairman of the task force that revised the last edition.

Dr. Frances, now an emeritus professor at Duke University, has been criticizing the current process relentlessly in blog posts and e-mails. Dr. Robert L. Spitzer, who oversaw revision of the third manual in 1980, has also voiced concerns, as have the American Counseling Association, the British Psychological Society and a division of the American Psychological Association. Some of the concerns have to do with important technical matters, like the statistical reliability of diagnostic questionnaires. Others are focused on proposed changes to the most familiar diagnoses.”

There are those who will say, at times with merit, that pharmaceutical companies act only to provide substantive relief to humans in distress. This is no doubt true in some instances, but then there are drugs like Paxil (Paroxetine) which has been found to increase suicidal tendencies in teens, addiction in the form of dangerous withdrawal symptoms and other problems. Yet at the time I retired it was widely used by my patients, via Psychiatrist’s prescription and I knew of a few instances of very negative consequences. This Wikipedia article may give you a fair idea as to why this widely prescribed medication is highly controversial.  Paxil, nevertheless is a highly profitable drug and so its producers are quite hesitant to shut down the “cash cow” even if the results are dubious. It must be understood of course that Paxil cannot be prescribed without a DSM diagnosis code and so its producers have a financial interest in this esteemed manual.

“Paroxetine [Paxil] is used to treat major depression, obsessive-compulsive disorder, panic disorder, social anxiety, Posttraumatic stress disorder and generalized anxiety disorder[1] in adult outpatients. Marketing of the drug began in 1992 by the pharmaceutical company SmithKline Beecham, now GlaxoSmithKline.”

Please note above that Dr. Zisook is a consultant for the Drug Companies that introduced Paxil. Also note that it is no longer used for teens and younger children due to the increased effect it has on suicidal ideation. However, if this new revision of the DSM is issued, with the inclusion of grief folded into depression, perhaps the teen market will be replaced by another market. Also note about Paxil”

“In the United States, the Food and Drug Administration requires this drug to carry a black box warning, its “most serious type of warning in prescription drug labeling,”[28] due to increased risk of suicidal ideation and behavior.”

Now just supposing we have someone grieving for a loved one, finding it hard to cope. The person goes to a Psychotherapist seeking relief from this burden. In order for the Psychotherapist to get paid they need a DSM Diagnostic Code for the patient and with the revised DSM V the psychologist categorizes this person as being in a depressed state. Most Psychotherapists today have a Psychiatrist they work with. The depressed patient is sent to the Psychiatrist for an evaluation  and in order to get paid the Psychiatrist will generally use the diagosis already agreed upon. Seeing the patient in distress and that distress is defined as Depression, the Psychiatrist prescribes Paxil. This patient just happens to be, and there is no way to wean this out, one of those people in which Paxil produces suicidal ideation and in a disastrous confluence the patient kills themself. Since the Jonathan Turley Blog is primarily a legal blog you can follow this link for information about Paxil side effects lawsuits, which seem to have had some litigation success and perhaps ponder the Tort liability issues entailed.

My experience in Mental Health though, has made me rather cynical about the accuracy of many mental health diagnoses. Certain diagnoses, depending on the era, become popular among Mental Health professionals and thus they are given to a higher number of patients. Put another way, many mental health professionals project onto their patient’s symptoms, disorders that are au currant. Many of the diagnostic fads are pushed by Mental Health professionals who have staked a claim on a particular diagnosis. Perhaps they have written a book, or a paper, showing their success with a particular treatment regimen. In many cases their treatments and studies have been underwritten by Drug Companies.  I believe that the pressure that Corporations face to ever increase profits, lest their share price goes down, produces a response to push more and more drugs onto people by finding new problems to treat and/or expanding the amount of patients who have a diagnosis treatable with the drugs they produce. This is true of the huge industry that is Mental Health and the monetary stakes are such that in this case “better living through chemistry” doesn’t apply to plastics.

My experiences with the various iterations of DSM’s are that they are not precise diagnostic tools, but only work as a kind of descriptive shorthand between MH professionals. A common thought among those trained to use these manuals is that when you first start to read them, you will think you have every psychiatric condition in the book. This is based firmly in truth. These are imprecise definitions, agreed upon through a quasi-political process, often not grounded in persuasive data, which are influenced by economic and political considerations. Again from the NY Times article:

“Under the current criteria, a depression diagnosis requires that a person have five of nine symptoms — which include sleeping problems, a feeling of worthlessness and a loss of concentration — for two weeks or more. The criteria make an explicit exception for normal grieving, which can look like depression. “

When I talk of imprecise definitions think about the ones iterated in the quote above, which are three of the five needed for a diagnosis of Depression. Having been there, I know that the loss of loved ones would cause someone at least two weeks of sleeping problems, one might well feel worthless because they couldn’t save their loved one and certainly their concentration would be shaky. My training as a Psychotherapist and per the DSM, taught me the period of recovery from grief should normally take about six months in an average human. A normal person never ceases to feel the pain of their loss, but usually after six months they have come to terms with the fact that their loved one will never return, which will nevertheless pain them for the rest of their lives. Redefine grief and then send those with a loss to a Psychiatrist after two weeks and I’m positive that medications will be prescribed in nine out of ten times. To me this redefinition is reeking of increased profits for the Drug Companies and also an increased patient load for the Mental Health Community, increasing their profits as well.

To my mind and in my personal experience, almost every human feeling grief would have at least five of the nine symptoms. The question is does grief need to be treated by a Mental Health professional, or is it a part of life that we all must face? I believe most of us have, or can develop the capabilities within to cope with our loss and move on in our lives. I understand that for some it might be unbearable to the extent that help is needed and I believe when that occurs they should get that help. I contend, however, that by incorporating grief into the diagnostic structure of depression, many people would be pushed into treatment and medication for a problem they can deal with via support of loved ones and their own internal strengths. It is perhaps my cynical nature that thinks the impetus behind this redefinition of grief, is patients and profits. This seems logically true because if you look again at the nine diagnostic criteria for Major Depression, any clinician if necessary, can now use current diagnostic code for Major Depressive Disorder to insure their payment and any medication’s drug coverage. If this is the case, why change it?

The Mental Health System in our country and indeed the world is truly much less scientific than laymen believe. There is excellent knowledge that has already been developed in the study of the human mind and its processes, but like other fields of endeavor our knowledge is incomplete and flawed by the self interest of some in the field. In the area of the human condition we call grief; I can guarantee that every human being will be touched by the chill of its emptiness. As mortal beings this horrible feeling is inescapable and yet for most of us we learn to go on and perhaps grow in some way from the experience. To my mind a battle is being fought over grief, out of sight of the public, to take an intrinsic aspect of the human condition and find a way to profit from it. So what else is new?

Submitted by: Mike Spindell, guest blogger

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