there. I have had the serendipity to come across a recent article in the
New York Times by one of the psychiatrists on the DSM-IV taskforce.
Shoot she/he's actually the chairperson of DSM-IV, not Robert Spitzer
which is what I thought. Anyway, there's a bit I want to snip out of
this but the whole piece is really good. It's the bit about
understanding that psychiatrists aren't trying to do something malicious
or evil with the possible medicalisaton of grief.
http://www.nytimes.com/2010/08/15/opinion/15frances.html
"
A startling suggestion is buried in the fine print describing proposed
changes for the fifth edition of the Diagnostic and Statistical Manual
of Mental Disorders — perhaps better known as the D.S.M. 5, the book
that will set the new boundary between mental disorder and normality. If
this suggestion is adopted, many people who experience completely normal
grief could be mislabeled as having a psychiatric problem.
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.
It is not that psychiatrists are in bed with the drug companies, as is
often alleged. The proposed change actually grows out of the best of
intentions. Researchers point out that, during bereavement, some people
develop an enduring case of major depression, and clinicians hope that
by identifying such cases early they could reduce the burdens of illness
with treatment.
This approach could help those grievers who have severe and potentially
dangerous symptoms — for example, delusional guilt over things done to
or not done for the deceased, suicidal desires to join the lost loved
one, morbid preoccupation with worthlessness, restless agitation,
drastic weight loss or a complete inability to function. When things get
this bad, the need for a quick diagnosis and immediate treatment is
obvious. But people with such symptoms are rare, and their condition can
be diagnosed using the criteria for major depression provided in the
current manual, the D.S.M. IV.
What is proposed for the D.S.M. 5 is a radical expansion of the boundary
for mental illness that would cause psychiatry to intrude in the realm
of normal grief. Why is this such a bad idea? First, it would give
mentally healthy people the ominous-sounding diagnosis of a major
depressive disorder, which in turn could make it harder for them to get
a job or health insurance.
Then there would be the expense and the potentially harmful side effects
of unnecessary medical treatment. 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.
In this we are not unique. Chimpanzees, elephants and other mammals have
their own ways of mourning. Humans have developed complicated and
culturally determined grieving rituals that no doubt date from at least
as far back as the Neanderthal burial pits that were consecrated tens of
thousands of years ago. 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.
There is still time to keep the suggested change from entering the
D.S.M. 5, which will not be published until May 2013. The task force
preparing the new manual could adopt a more cautious and modest
estimation of the reach of psychiatry and its appropriate grasp.
For the few bereaved who are severely impaired or at risk of suicide,
doctors can already apply the diagnosis of major depression. But don't
change the rules for everyone else. Let us experience the grief we need
to feel without being called sick.
Allen Frances, an emeritus professor and former chairman of psychiatry
at Duke University, was the chairman of the task force that created the
fourth edition of the Diagnostic and Statistical Manual of Mental Disorders.
"
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