Sunday, August 15, 2010

Medicalizing Normal Grief

I've never met Allen Frances, whose distinguished psychiatric career has included chairing the DSM IV Task Force and the Department of Psychiatry at Duke. But I've admired him ever since reading an article he wrote in 1981 - "No Treatment as the Prescription of Choice" - in which he discussed the range of human situations that involve distress or odd behavior but should not be brought under the microscope of psychiatric treatment.

Today Dr. Frances has an Op Ed in the New York Times that challenges the way the American Psychiatric Association draft of DSM V is construing the relationship between grief (a "normal" process) and major depression (an "illness"). My admiration for his lucidity and good sense holds steady. Here's the gist of his argument:
Suppose your spouse or child died two weeks ago and now you feel sad, take less interest and pleasure in things, have little appetite or energy, can’t sleep well and don’t feel like going to work. In the proposal for the D.S.M. 5, your condition would be diagnosed as a major depressive disorder.

This would be a wholesale medicalization of normal emotion, and it would result in the overdiagnosis and overtreatment of people who would do just fine if left alone to grieve with family and friends, as people always have. It is also a safe bet that the drug companies would quickly and greedily pounce on the opportunity to mount a marketing blitz targeted to the bereaved and a campaign to “teach” physicians how to treat mourning with a magic pill.

...Because almost everyone recovers from grief, given time and support, this treatment would undoubtedly have the highest placebo response rate in medical history. After recovering while taking a useless pill, people would assume it was the drug that made them better and would be reluctant to stop taking it. Consequently, many normal grievers would stay on a useless medication for the long haul, even though it would likely cause them more harm than good.

The bereaved would also lose the benefits that accrue from letting grief take its natural course. What might these be? No one can say exactly. But grieving is an unavoidable part of life — the necessary price we all pay for having the ability to love other people. Our lives consist of a series of attachments and inevitable losses, and evolution has given us the emotional tools to handle both...It is essential, not unhealthy, for us to grieve when confronted by the death of someone we love.

...Turning bereavement into major depression would substitute a shallow, Johnny-come-lately medical ritual for the sacred mourning rites that have survived for millenniums. To slap on a diagnosis and prescribe a pill would be to reduce the dignity of the life lost and the broken heart left behind. Psychiatry should instead tread lightly and only when it is on solid footing.
Wise thoughts, wonderfully well articulated!


eric said...

Jim—Well said! Arthur Kleinman, M.D., and Peter Benson stated the
following in The Mount Sinai Journal of Medicine for October, 2006, in their article, “Culture, Moral Experience and Medicine:”

“Medicalization itself becomes an obstacle in human relationships. It makes neat groups of people who
either do or do not have certain disorders, rather than people who participate in common experiences,
such as unhappiness, fear, distress, and social transformation. It is more difficult to understand
how calamities large and small affect ordinary people when ordinary suffering is recast in
terms of medical pathology. Three quarters of hospitalized
terminally ill patients in the last weeks of life have most of the symptoms of DSM-IV depression
based on inanition, symptoms of disease, effects of medication, and response to terminal
care. In our view, they are not clinically depressed.
They are experiencing serious suffering, a crucial
moral condition: one that doctors of past generations recognized and dealt with as fundamental to
living and dying with meaning. Calling them depressed
is often a conversation stopper—time for antidepressant drugs. When what is often needed is a conversation opener so that people at the end of life can express and explore the most tellingly human of fears and concerns.” (page 838) Thank you.--Eric

Jim Sabin said...

Hi Eric -

Great to hear from you. And, thank you for the beautiful quote from Arthur Kleinman's article, which expresses what I wanted to convey much better than I could.

Many years ago, my beloved father-in-law was suffering from advanced heart failure. As Arthur Kleinman described, he had all the symptoms of "major depression," but he was offended when his cardiologist suggested an antidepressant medication. I was very close to him, as was my niece, his granddaughter, a distinguished psychologist. Neither of us thought he should be treated for depression. We said to each other - "if his psychologist granddaughter and psychiatrist son-in-law are missing the boat on this it would be terrible."

What we did instead was to seek out a second cardiologist, who shifted his heart regimen and relieved the worst shortness-of-breath symptoms. The "depression" went away, replaced by "normal sadness" and the calm, loving characteristics that made him such a beloved person. He died peacefully in his sleep not too long afterward.