On the Op-Ed page of the August 15, 2010 New York Times Allen Frances wrote under the title Good Grief that the proposed DSM 5 would medicalize normal grief and lead to overdiagnosis and overtreatment of normal grief which would be diagnosed as Major Depressive Disorder. I know from other publications as well as interviews that Dr. Francis, former chair of the Dept of Psychiatry at Duke and chair of the committee that was responsible for the production of DSM-IV, believes they overreached in that manual leading to an epidemic in diagnosing and thus treating ADHD, childhood bipolar disorder, and autism. He has alluded to the bonanza that the pharmaceutical industry reaped from these decisions. Without doubt ring fencing a particular set of symptoms and labeling them with a diagnosis can be problematic when the phenomenology is not bound to the underlying genotype and chemistry. That is not currently available for psychiatric illnesses though progress is at hand as alluded to in my blog, The Future of Psychiatry.
Life is a series of attachments and detachments in the form of losses (bereavement, divorce, bankruptcy, rape, loss of health or body limbs, etc) and a mourning process is natural and healthy. DSM-IV carves out bereavement as a normal process as long as it is less than eight weeks. The process involves a complex latticework of psychological and physiological responses to the memory of the lost one. These responses span a period of time and are taken up seriatim in a manner similar to examining each piece of a jigsaw puzzle and gradually assembling it until it is complete and can be put away on a shelf. I have seen this take place in as little as four weeks and as long as sixteen weeks. When the period exceeds ten weeks, it is often difficult to distinguish it from a Major Depressive Disorder. The different forms of bereavement and its differentiation from Major Depressive Disorder go beyond the scope of the brief article.
It is clear to me that Dr. Frances has strong feelings about psychiatry changing diagnostic standards and overdiagnosing so as to reduce the area of normality and increase the number and amount of treatment rendered. He talks about labels causing problems securing a job or insurance (or security clearances) and using medication could produce improvement either by placebo effect or neurophysiological effect. He labels such pills "useless pills."
I view this last statement as ill-advised because the current Zeitgeist is one of looking for conspiratorial activity by the pharmaceutical industry whose image has been damaged by revelations of financial conflicts of interests on the integrity of the medical profession and academic medical centers as well as publication bias in which failed trials are not published. Another point is that pills that produce a placebo effect are in fact producing a result. This should be considered in light of the fact that most depressed people get their care from a PCP. If there are sixteen million depressed people at any one time in the United States then six percent placebo response is almost one million people and twelve percent is almost two million - a not insignificant number. We should also keep in mind that the FDA requires only two positive trials and ignores the failed trials. Journals are also reluctant to publish failed trials.
When the individual migrates into the land of Major Depressive Disorder he/she should be treated with medication as one modality. Let us not forget that depression is under-treated in the short-term and long-term, produces a staggering amount of disability and is a brain killer. Depression has been shown to be associated with decreases in brain-deriver neurotrophic factor (BDNF) and increases in glucocorticoids, inflammatory cytokines, and oxidative stress. Every new depressive episode increases the risk of additional episodes leading to chronicity. Long-term prophylaxis is recommended after two episodes that have each lasted more days than not for two weeks.
Finally a few comments about antidepressants. In the January 29 cover article in Newsweek, "The Depressing News About Antidepressants." the idea that antidepressants don't work or don't work better than placebo was discussed. That conclusion was based on a January 6 article in the Journal of the American Medical Association which concluded that the benefit of antidepressants when compared to placebo was greatest as the severity of the depression increased and that they were minimally effective for patients with mild or moderate symptoms. The popular press misunderstood the meaning of this article because they misunderstood the meaning of the placebo effect. In clinical practice you can either prescribe a drug, do psychotherapy, or do nothing and wait. Doing nothing and waiting is not the equivalent of a number of sessions in a placebo controlled trial. Several researchers have also commented that the placebo response has increased in recent years due to study design and the study subjects not falling on a random distribution curve.
Lost in all this controversy were some very hard findings about antidepressants. They have been shown to increase neurogenesis and neuroprotective factors such as BDNF, prevent stress from decreasing BDNF in the hippocampus (short term memory), prevent decrease in hippocampal volume, and show positive effects on longevity and medical health.
It seems to me that researching the genetics, neurobiology, and neurophysiology would be much more productive that arguing about where certain diagnostic lines should be drawn. The research will draw the line. Hum I wonder what the Chinese are doing right now?