When does a broken heart become a diagnosis?
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 criteria for depression are being reviewed by the American Psychiatric Association, which is finishing work on the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., the first since 1994. The manual is the standard reference for the field, shaping treatment and insurance decisions, and its revisions will affect the lives of millions of people for years to come.
In coming months, as the manual is finalized, outside experts will intensify scrutiny of its finer points, many of which are deeply contentious in the field. A controversy erupted last week over the proposed tightening in the definition of autism, possibly sharply reducing the number of people who receive the diagnosis. Psychiatrists say current efforts to revise the manual are shaping up as the most contentious ever.
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.
But 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.
In blogs, letters, and editorials, experts and advocates have been busy dissecting the implications of this and scores of other proposed revisions, now available online, including new diagnoses that include “binge eating disorder,” “premenstrual dysphoric disorder” and “attenuated psychosis syndrome.” The clashes typically revolve around subtle distinctions that are often not readily apparent to those unfamiliar with the revision process. If a person does not meet precise criteria, then the diagnosis does not apply, and treatment is not covered, so the stakes are high.
“The world has changed” since the last revision, in 1993, said Dr. James H. Scully Jr., chief executive of the psychiatric association. “We’ve got electronic media around the clock, and we’ve made drafts of the proposed changes public online, for one thing. So anybody and everybody can comment on them, at any time, without any editors.”
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 twopsychiatrists 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.
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.
But the proposed diagnosis of depression has no such exclusion, and in the new study,Jerome C . Wakefield of New York University and Dr. Michael First of Columbia concluded that the evidence was not strong enough to support the change. “An estimated 8 to 10 million people lose a loved one every year, and something like a third to a half of them suffer depressive symptoms for up to month afterward,” said Dr. Wakefield, author of “The Loss of Sadness.” “This would pathologize them for behavior previously thought to be normal.”
But Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh School of Medicine and the chairman of the task force making revisions, disagreed, saying, “If someone is suffering from severe depression symptoms one or two months after a loss or a death, and I can’t make a diagnosis of depression — well, that is not being clinically proactive. That person may then not get the treatment they need.”
Another point of growing contention is a proposed new diagnosis, “attenuated psychosis syndrome,” which would be given to people who experience delusional thinking andhallucinations and sometimes say things that do not make sense. Psychosis is the signature symptom of schizophrenia, typically a lifelong, disabling mental disorder. Psychiatrists have long hoped for a way to catch it early, before it turns into full-blown schizophrenia.
But critics say these symptoms are poor predictors of the disorder. In studies, 70 percent to 80 percent of young people who report these strange experiences do not ever qualify for a full-blown schizophrenia diagnosis, yet the label increases the risk of being “treated” with powerful anti-psychosis drugs.
“There’s already overuse of these drugs in children and adolescents, and having this vague diagnosis, regardless of its intent, will only increase misuse in this vulnerable population,” said Dr. Peter J. Weiden, director of the psychosis treatment program at the University of Illinois at Chicago.
Some outside experts say the same is true of other proposed additions, like premenstrual dysphoric disorder (lethargy and other depressive symptoms in the week before menses, among other things) and binge-eating disorder (out-of-control bingeing, complete with self-loathing). Getting the diagnosis increases the likelihood of being treated for what is normal behavior, or close enough.
Task force members argue differently: If a person is in distress and seeking help, then treatment ought to be offered — and covered by insurance.
For now, these revisions are still in play; the completed manuscript is due to the printer in December. In the longer term, the politicking is likely to have a corrosive effect on the process, some experts said. Recent findings in genetics show that nature does not respect psychiatric categories — many different disorders seem linked to some of the same genetic glitches.
Already a federal agency, the National Institute of Mental Health, has set up its own independent effort to classify mental disorders, called Research Domain Criteria, based on research findings rather than existing categories.
In time, said Dr. Steven E. Hyman, a resident scholar at the Broad Institute of M.I.T. and Harvard, this kind of approach should ground the field more in nature and less in expert opinion. Until then, there is and will be the diagnostic manual.
This article, "Depression's Criteria Might Include Grieving," first appeared in The New York Times.