Generation Meds

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Live-Blogging the 2013 APA Annual Meeting: Sunday

Mitigating Alzheimer's risk, and pondering the DSM-5's "bereavement exclusion."

apa meeting logo
For the next few days, I'll be blogging what I see and learn at the American Psychiatric Association's annual meeting—which, this year, happens to be just a convenient, cross-bay train ride from where I live. Here's my report from day one.

Acclimation

Sunday wasn't technically day one of the APA meeting; yesterday was. But since I had a commitment that I couldn't move yesterday, today was my first. I arrived at downtown San Francisco's giant conference facility, the Moscone Center, around 1:30 this afternoon.

I felt excited to be attending APA, since I've been reading about this gathering for years. It is the largest and most famous meeting of psychiatrists in the U.S. and maybe the world, and plenty of journalists have taken a crack at it. I had read several accounts over the years that made this big tribal gathering sound overwhelming and sometimes bizarre, and I wanted to see it for myself.

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As I approached Moscone, I walked past a small collection of anti-psychiatry protesters on a traffic island outside. Otherwise, the streets were calm and normal, in a San Francisco kind of way. Psychiatrists wearing plastic nametags alternated with Bay To Breakers revelers wearing colorful skintight costumes.

To find the press room inside of the Center, I had to walk around a bit, and as I did, many of the expectations that I'd built up from reading about APA conferences of the late '90s and early 2000s were dashed. The hall did not look like a place where a pharmaceutical-industry piñata had just been smashed, showering promotional tchotchkes everywhere. Instead, the vibe was sleek and staid: just a few thousand MDs in business casual, doing their thing.

In fact, the only aspect of descriptions I'd read that have held up so far are accounts of the APA's mind-boggling size. The program book for the five-day meeting is 320 pages long, with multiple interesting-sounding sessions happening at the same time as one another, in every time slot, from now till the meeting closes on Wednesday. I was glad I wore sneakers. It's going to be a big few days.

2pm-3:30: The Skinny on Alzheimer's

I started by barging into a 'distinguished psychiatrist' lecture on Alzheimer's disease and brain health, given by Dr. Gary Small, director of the Longevity Center at UCLA.

Small was reviewing what we know about Alzheimer's and how to prevent it.

A little random, but a topic of personal interest. Also perhaps a decent way to kick off a meeting dedicated to the medical study of human cognition and emotion, since Alzheimer's disease is one of those things that forces you to concede, as uncomfortable and/or counter-intuitive as it may be, that the brain is just another organ—one that wears out, breaks down, clogs up with junk, and basically ceases to function as well as it once did, on its way to ceasing to function at all.

Dr. Small explained that there are still no medications that address Alzheimer's disease at its roots. Research continues, along several avenues (he's involved right now in a study of circumin, the anti-inflammatory compound in turmeric).

In the meantime, he is intrested in prevention. There's good evidence that a lot of lifestyle changes—the kinds of changes you should probably be making anyway—reduce at least the probability of getting Alzheimer's by a lot. Physical exercise, mental activity, stress management, and nutrition (specifically, eating plenty of omega-3 fatty acids in the form of fish and nuts, and avoiding refined sugar and processed foods) all play a role.

As Dr. Small was talking, I started to wonder whether overweight/obesity, nutrition, and possibly exercise will emerge as themes of the meeting. (I'd noticed them popping up several places in the program; if nothing else, they would fit this year's tagline, which is "Pursuing Wellness Across the Lifespan.")

According to Small, being overweight doubles one's risk of Alzheimer's; being obese quadruples it. Besides all the other benefits they enjoy, people who lose weight and start exercising report having better memory—and research confirms it.

3:30-5pm: First DSM-5 Conversation of the Week (but probably not the last)

After the Alzheimer's lecture, I bought a coffee and sat down to look at the program. Soon I was joined by a psychiatrist with a snack of his own. He was from Lebanon. I asked him what he'd seen that morning and he told me he'd been to a session on the revised criteria for depression in DSM-5.

If you follow psychiatry at all, you probably know that just yesterday was the official unveiling of DSM-5, the all-new, revised-and-expanded version of the diagnostic "Bible" of psychiatry. In these periodic revisions (the last big one was in 1994), the criteria that are used to define mental disorders are adjusted. Certain disorders are thrown out, and new ones are added.

It's a controversial process, largely because it shines a light on how arbitrary psychiatric 'diseases' can be. Other branches of medicine have their share of arbitrariness too—as the author Gary Greenberg, who has a new book out about DSM-5, pointed out in a talk I heard him give last week. But the arbitrariness of psychiatry seems to bother people more: maybe because it's easier to see, maybe because mental disease is more stigmatized than physical disease.

Anyway, the psychiatrist told me he'd been hearing about what's new in depression. Specifically, he mentioned how the so-called "bereavement exclusion" for depression has been scrapped.

The "bereavement exclusion," if you haven't heard of it, was a piece of the diagnostic criteria that used to say that if a person had recently suffered the death of a loved one, they should not be diagnosed with depression, even if they were displaying enough symptoms to qualify for the diagnosis otherwise. It was a recognition that people who are in an acute state of grief often meet all the criteria for clinical depression—but that this grief reaction isn't a 'disorder' as such.

The exclusion didn't prevent psychiatrists from prescribing therapy or antidepressants to the recently bereaved. It just said that bereaved people's depressive symptoms shouldn't be considered signs of depressive illness.

Removing the bereavement exclusion has been a controversial move, discussed and debated a lot—in the press as well as on the committees that wrote the book—before DSM-5 went to press. In the end, APA decided to drop the bereavement exclusion. Now, a diagnosis can be given to anyone who displays the symptoms of depression at a severity that interferes with normal functioning for at least two weeks—even if that person lost a spouse, parent, or child just a couple of weeks before.

I asked the psychiatrist how he felt about removing the bereavement exclusion, and he said he thought it was a good thing. He asked me how I felt.

I think it's terrible!, I said. I think it's offensive!

The psychiatrist looked surprised, and I tried to explain. Losing a loved one is traumatic. It produces many signs and symptoms of depression in almost everyone. Given that this reaction is near-universal, it seems outrageous to define the state of grief as a disorder. I'm not saying that people who are in a state of grief don't need or want help—but what happened to support, listening, taking time to adjust? If drugs come into the picture, why can't they be 'to take the edge off' or 'to help you get though this hard time'? How can telling a newly bereaved person that their emotions are pathological possibly help? It's so arrogant. It's so unfeeling. It's so…yeucch.

The psychiatrist looked genuinely confused. No, he said. No, it's not like that at all.

He went on to talk about how it's good to get rid of this exclusion because it's good for psychiatrists to be able to get people help right away. (But there was nothing stopping them in the first place, I wanted to say.) Mental disorders like depression and schizophrenia literally eat away at your brain, he added. People who become depressed may not be able to get back out.

Then he told me a personal story. He lost someone very close to him seven years ago. It changes you, he told me. Things haven't been the same since. His outlook on life is a little different, not as positive as it once was.

I asked him whether he would have wanted an intervention. Yes, he said, I think so. I asked what kind. Some psychotherapy, maybe, he said. I got some later, but I think it was already too late.

We didn't settle the point: whether grief is "natural," even to the point of changing and becoming a darker person for good. Whether if it's natural it's to be embraced. Whether feeling depressed after a loved one's death should be called an illness or not, and whether what you call it is important, in terms of helping people.

I'm still inclined to find the axing of the bereavement exclusion obnoxious. It lops off one of the last vestiges, in the DSM, of the old idea that mental disorder has anything to do with context, that people ever feel a way because of a reason. Talking about context in a way that applies to everyone is difficult—by defintion, it's contextual, not one-size-fits-all. But I think that not being able to find any room for context is one reason why psychiatry has become so vulnerable lately to charges that it isn't capable of distinguishing what's normal from what's not.

Even though we didn't exactly find a way to agree about the exclusion, it was an interesting conversation, one that eventually made its way to plenty of other topics, and ended in a Facebook friending. Score.

5:30pm: Not seeing Bill Clinton

The keynote address on Sunday night was to be given by President Bill Clinton, and I was looking forward to it. Obviously, Clinton is a legendary speaker. While his connection to mental health issues is not obvious, imagining what he might have to say was part of the fun. Maybe he was going to talk about how adopting a vegan diet hasn't just helped him lose weight, but has made him happier too? Okay, probably not. At any rate, I didn't get to find out, because at the door to the mammoth ballroom in Moscone North, I was gently but firmly stopped by a security guard who told me that press aren't allowed at this keynote.

The blow was softened slightly when I read on a monitor that the President was under the weather and would be appearing by satellite rather than live. Still, I'm curious what his message was, and looking forward to getting filled in on that tomorrow.

Is there anything you want to have reported, from or about the conference? I can't promise to deliver, but I'd love to know. Please leave a comment below.

 

Katherine Sharpe is the author of Coming of Age on Zoloft.

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