DSM5 in Distress

The DSM's impact on mental health practice and research

DSM 5 to the Barricades on Grief

Defending The Indefensible

The storm of opposition to DSM 5 is now focused on its silly and unnecessary proposal to medicalize grief. DSM 5 would encourage the diagnosis of 'Major Depressive Disorder' almost immediately after the loss of a loved one—having just 2 weeks of sadness and loss of interest along with reduced appetite, sleep, and energy would earn the MDD label (and all too often an unnecessary and potentially harmful pill treatment). This makes no sense. To paraphrase Voltaire, normal grief is not 'Major', is not 'Depressive,' and is not 'Disorder.' Grief is the normal and necessary human reaction to love and loss, not some phony disease.

All this seems perfectly clear to just about everyone in the world except the small group of people working on DSM 5. The press is now filled with scores of shocked articles stimulated by two damning editorial pieces in the Lancet and a recent prominent article in the New York Times.

The role of public defender of DSM 5 has fallen on John Oldham MD, president of the American Psychiatric Association, and a good friend of mine for 45 years. John is a smart and good person placed by the unkind fates in the unenviable position of having to defend untenable DSM 5 decisions. He makes a soldierly attempt- but his arguments ring hollow and are tone deaf to the dangers of the DSM 5 proposal and all the obvious reasons it has met such universal scorn. I wish it were someone else on the other side of this question, but there is no alternative but to show the four ways in which Dr Oldham's arguments badly miss the point.

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Dr. Oldham defense can be accessed here.

1) "When we say that we are recommending removing this exclusion of grief from the diagnosis of depression, people have misinterpreted this to mean that therefore everyone who is grieving after the loss of a spouse will be diagnosed as depressed. That is not at all the case. Even if you meet the criteria for depression, it doesn't mean that you're going to have treatment slapped on you. It just means that maybe you'd have a conversation about it with your doctor and perhaps agree to a watchful waiting period and be alert to how things go and maybe check in a little more frequently. Nothing is automatic; there are lots of options."

Annotation: Nothing could betray more clearly the ivory tower world view that consistently leads DSM 5 astray. In the real world, most diagnosis of mental disorder and most prescription of medicine is done by primary care doctors—who have little training in psychiatric diagnosis, spend fewer than 10 minutes with each patient, and are often influenced by drug company marketing. There is no way that even the most skilled psychiatrist can distinguish normal grieving from mild depression—we must not expect primary care doctors to do it. Watchful waiting is wonderful—but all too rare. Drug companies will jump greedily into this vast new market. This is not at all APA's intent, but it is a dreadful unintended consequence that must be (but hasn't been) factored into a complete risk/benefit analysis.


2) Dr Oldham notes that the DSM IV bereavement exclusion is "very limited; it only applies to a death of a spouse or a loved one. Why is that different from a very strong reaction after you have had your entire home and possessions wiped out by a tsunami, or earthquake, or tornado; or what if you are in financial trouble, or laid off from work out of the blue? In any of these situations, the exclusion doesn't apply. What we know is that any major stress can activate significant depression in people who are at risk for it. It doesn't make sense to differentiate the loss of a loved one as understandable grief from equally severe stress and sadness after other kinds of loss."

Annotation: Yes indeed. 'Major Depressive Disorder' is currently applied carelessly and inappropriately to the expectable reactions people also have to others of life's severe stresses—divorce, loss of job, financial difficulties, etc. This is precisely why studies so often show no advantage for medication over placebo in the treatment of depression—many of the people studied aren't really depressed. There is an obvious opposite solution that would correct this and also achieve the consistency Dr Oldham seeks. DSM 5 shouldn't broaden MDD to include grief—rather it should narrow MDD to cover only real depressions. Consistency and more accurate diagnosis can be achieved by raising the severity and duration requirements for 'Major Depressive Disorder' whenever symptoms occur in the context of a powerful stressor.

3) "We want people to get treatment who need it."

Annotation: They already do. DSM IV is completely explicit that the MDD diagnosis should be made whenever grief has clearly turned into depression—ie when the bereaved becomes suicidal, or psychotic, or has severely impairing symptoms, or has had similar depressive episodes before. DSM IV aint broke on this, making the DSM 5 fix even more nonsensical.

4) Dr Oldham says this was not a snap decision. "There was a lot of very thoughtful discussion about it. Nobody saw it as just clear as it could be. It was not an immediately agreed upon consensus. This is something that is sensitive and needs to be thought about carefully, and we recognize that"

Annotation: The DSM 5 decision making process is puzzling and opaque in the extreme. A small group of otherwise very smart people make a decision that solves no outstanding problem, is based on no credible scientific literature, arouses remarkably strong opposition among mental health and medical professionals, creates a frenzy of press scorn, and seems crazy and insulting to the community of grievers. The consensus that needed achieving was not within the narrow confines of a few die hard DSM 5 enthusiasts. DSM 5 is a document with wide public health and public policy implications. It must represent a consensus of the literature and of the field. Instead, it is now DSM 5 against the world. This is no way to develop the consensus needed in an official diagnostic system.

The interesting but very sad thing is that Dr Oldham leaves absolutely no running room for DSM 5. He could have said something like: "This change is still being studied. It is still just a draft proposal and we are very grateful for all the input which will certainly go into the final decision." Instead, he paints himself into a tiny corner, stalwartly defending the indefensible.

This is clear writing on the wall that the DSM 5 decisions on many other equally reckless proposals are also written in stone. If DSM 5 won't back down in the face of this extraordinary pressure on grief, it is probably dug in on many of its other controversial and harmful proposals. My previous lingering hope that external opposition might lead to useful compromises was naively predicated on the overly optimistic assumption that the American Psychiatric Association would follow the rational path, cut its losses, and reject the worst DSM 5 suggestions. Instead, it is APA to the barricades.

So where do we stand? Most likely scenario: The press will increasingly pick DSM 5 apart and expose all of its considerable risks. APA will keep missing the point, continue to provide lame defenses, and follow its blind momentum forward to a premature publication date. A lamentably poor quality and terribly risky DSM 5 will be published. DSM 5 will be roundly rejected outside the United States and will have greatly diminished sales (and hopefully influence) within. But the drug companies will aggressively promote its suggestions to swell further the already swollen sales of antipsychotic, stimulant, antidepressant, and anti-anxiety drugs. The epidemic of childhood obesity will get worse; the illegal market in stimulants will flourish; polypharmacy will increase; and the severely ill will continue to get short shrift- and all sorts of other harmful unintended consequences will also flourish.

Up until this point, I had hoped DSM 5 could save itself if only enough pressure were applied to make it see the light. This no longer seems likely and government intervention is probably the last (and possibly the only) resort.

 

Allen Frances, M.D., was chair of the DSM-IV Task Force and is currently professor emeritus at Duke.

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