Up until now, the leadership of the American Psychiatric Association has stubbornly defended the indefensible DSM 5 proposal that would turn normal grief into clinical depression. APA has blithely ignored the contrary scientific evidence, the unified opposition of 47 professional organizations, two eloquent editorials in the Lancet, and critical articles in more than 100 newspapers from all around the world. The meager counterarguments offered by the APA and DSM 5 leadership reveal how badly they have lost touch with clinical common sense, with the larger community of mental health professionals, and with the general public.
Recently, Dr. Joanne Cacciatore wrote a moving blog opposing the DSM 5 plan. Within days, she had unexpectedly attracted more than 100,000 viewers. Encouraged by the display of overwhelming support, Dr. Cacciatore has now written a powerful letter to the APA Trustees demanding that they take immediate action to protect normal grief from inappropriate DSM 5 medicalization.
I think her letter could be the crucial turning point in the development of DSM 5. If the APA Trustees respond to it positively and finally exert appropriate governance of DSM 5 on this one point, they may feel empowered to review and revise other equally reckless DSM 5 proposals. If, instead, the Trustees again fall meekly into line backing this hopelessly foolish proposal, it is unlikely that DSM 5 will ever be a safe or scientifically sound system of psychiatric diagnosis.
Here is Dr. Cacciatore's letter:
Open Letter to the Board of Trustees of the American Psychiatric Association and to the DSM 5 Task Force
Two weeks ago, I wrote a blog opposing the DSM 5's proposal to reduce the DSM IV bereavement exclusion.
This blog has since gone viral in the most incredible way -- 100,000 readers within its first few weeks. It seems that this proposal is experienced as an outrageous insult by the very people it is intended to help.
I have more than sixteen years experience dealing with tens of thousands of grieving people whose children die or are dying at any age and from any cause. To my knowledge, there is no empirical standing for the arbitrary two-week time frame, and thus this proposal not only contradicts good common sense but also rests on weak scientific evidence.
One thing in which the literature is clear: long-term psychological distress is common in this population and other populations suffering traumatic deaths. In my experience both as a researcher and clinician in the field and also as a bereaved parent, the DSM 5 proposal is radical, unnecessary, challenges what it means to be human, and for some may be dangerous.
Those with severe depressive symptoms distinguishable from normal grief can already be diagnosed as soon as is needed using the DSM IV criteria. In contrast, DSM 5 would require a distinction between normal grief and mild depression shortly after the death of a loved one that is often impossible to discern for even the most experienced clinicians. The DSM 5 may well create problematic false positives -- and thus cause further harm, to an already vulnerable population. There are many more reasons we oppose these changes, many of which are outlined in my blog.
Our international organization (MISS Foundation) has 77 chapters around the world and has helped countless grieving families and the professionals who serve them. All our services are free and we are a volunteer-based organization. Our website gets more than one million hits per month and we have 27 online support groups. We oppose this change with our minds, with our hearts, and with our numbers.
I speak on behalf of the MISS Foundation's grieving families: Should the DSM 5 stubbornly ignore the evidence and the mounting professional and public opposition, our last alternative will be to call for more direct action -- in the short term, our organization will rally the support of Congressional leaders; in the longer term, we will have no choice but to join a concerted boycott against the use of the DSM 5 in treating bereaved families facing the death of a child.
Process transparency is also important. Please respond promptly with an indication of the next steps and timetable in the APA review process; what is the organizational table for making this decision; on what grounds will it be made; when will it be announced; and, is there an appeal process?
On behalf of hundreds of thousands of bereaved people around the world, I implore you to reverse this poorly conceived and unnecessary decision. My more than 100,000 readers and I hope to hear from you soon.
Thank you, Dr. Cacciatore. Heretofore, the APA leadership has provided no direction, creating a vacuum that allowed DSM 5 full freedom to chart its risky course. But expertise can come from many and unexpected quarters -- in this case it arrives in the surprising form of a spontaneous outpouring from 100,000 people who understand the topic of bereavement from the inside. The DSM 5 grief proposal was never needed, doesn't make sense, is gratuitously off-putting, and has placed psychiatry in the worst possible light. APA's misguided defense of it simply has no traction and has already dealt an unnecessary blow to the credibility of psychiatry.
Dr. Cacciatore's well-reasoned letter is a clear (and perhaps final) wake-up call to the APA Trustees. It is long past time for them to do some reality testing and also to show some gumption and responsible governance. Psychiatry is an essential and wonderful profession that deserves much better leadership than it has so far received throughout the DSM 5 fiasco. It has come down to a now-or-never moment for the leaders of APA to finally come to plate and curb obvious DSM 5 excess. They should not force those seeking a safe DSM 5 to the extremes of political action or boycott. This is the turning point for the APA leadership -- perhaps its last chance to set DSM 5 right.
Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force.
James H. Scully, Jr., M.D.: DSM-5 Inaccuracies: Setting the Record Straight
Randy Taran: Happiness Lost: When Kids Take Their Lives
"For whom are you advocating with such a hopelessly twisted process?"
For science. Science demands that you, critic or not, support your position with research. If you can't, you are not interested in science but you are engaging in politics. So far, all I have seen from the "critics" is politics. They could, for sure, not make their case with science. See the utterly failed cases below.
I still do not understand that you demand the critics produce proof; maybe I have not read enough on this page to have the proper context. Perhaps there are many kinds of critics, but I for one am simply pointing out the total absence of proof, a lack of scientific evidence, a gaping hole in years of research. This would be fine, an ongoing scientific inquiry, if it were not for the medical model of treatment that intimately interferes with family dynamics. This should be of interest to you, emotional or not, because it has to do with the persistent application of very bad science.
Not really. I have nothing to do with psychiatry, I have absolutely nothing to lose one way or another. I find it very questionable, though, that the man responsible for the last version of the DSM seems to be on a crusade against the new version.
"I still do not understand that you demand the critics produce proof"
Not proof, but civil, scientific discourse. I don't think we have seen much of that here. The problem for Dr. Frances and those who are attacking the DSM working group is that I, as an outsider, can't see what's going on inside the working group. He may be right, he may be wrong. I simply can't tell. But I can see the behaviour of the critics and I do not find it particularly appealing. So if I am going by what I can see here, I am automatically put off by his position, which is counter-productive to what he is trying to achieve.
"Perhaps there are many kinds of critics...."
I can't judge the state of the research. All I can say is that the papers presented by the critics HERE do not seem to make their point, at all. If anything, they seem to agree more with the DSM 5 proposal. That's also not a good sign for the critic's side.
Because otherwise the critics don't have the high ground in a mud fight, either. If they really cared about their case, they would fight this the right way, instead of engaging in counter-productive politicking.
Look at this mess... I had to ask for weeks to be given some citations... and then, when someone finally takes the time to dig some up, a closer look at their content actually supports the DSM 5 instead of negating it!
What does that tell you? It tells you that the "critics", at least here, haven't done their homework and are arguing from emotional, rather than rational positions.
Trust me, if Dr. Frances had the necessary scientific data to attack the DSM 5 working group with scientific arguments, he would. That he doesn't is, IMHO, a sign that he has chosen a non-defensible position. He was, by the way, responsible for the very language in the DSM IV that is now being criticised by the papers submitted below. So it is his work that is under scrutiny by scientific research, not that of the DSM 5 working group... at least on the bereavement issue.
I hope we can have a rational discussion on this topic. I, for sure, did try.
I think this goes to the heart of the matter. It is the question if someone wins the lottery, they should be diagnosed with mania. Context cannot be ignored in diagnosis. I think the idea is to have computers do diagnosis. I believe accuracy will demand human evaluations.
Is the social contract broken? Absolutely. Should that concern us? Yes. But that's a problem of raising kids in such a way that they feel a moral obligation to share. No psychiatrist in the world can make an adult egotist into a decent person.
Recently, Historians found that the discrepancy between rich and poor in America is now greater than any time in the Roman Empire.
It may be great for you, but I have always found that the DOW is inversely proportional to my standard of living.
I for one am fairly happy with the presented evidence, as it suggests that mistakes in the DSM IV will be eliminated in the next version.
Did narrowing the major depression bereavement exclusion from DSM-III-R to DSM-IV increase validity?: evidence from the National Comorbidity Survey.
Wakefield JC, Schmitz MF, Baer JC.
Related Depression and Anxiety: A Replication Study With Bereaved Mental Health Care Patients
Paul A. Boelen, M.A.; Jan van den Bout, Ph.D.; Jos de Keijser, Ph.D.
Am J Psychiatry 2003;160:1339-1341. 10.1176/appi.ajp.160.7.1339
OMEGA--Journal of Death and Dying
Issue: Volume 48, Number 3 / 2003-2004
Pages: 263 - 277
URL: Linking Options
AN EMPIRICAL STUDY OF THE PROPOSED COMPLICATED GRIEF DISORDER CRITERIA
NANCY S. HOGAN A1, J. WILLIAM WORDEN A2, LEE A. SCHMIDT A3
A1 Loyola University, Chicago, Illinois
A2 Rosemead School of Psychology, La Mirada, California
A3 University of Miami, Coral Gables, Florida
I couldn't access the full text of the first reference, so I can't comment on it in detail. The language in the abstract is ambiguous as to the effect of the study on the exclusions criterion. The same authors seem to have published a new version of the paper in
"Does the DSM-IV Clinical Significance Criterion for Major Depression Reduce False Positives? Evidence From the National Comorbidity Survey Replication"
Jerome C. Wakefield, Ph.D., D.S.W.; Mark F Schmitz, Ph.D.; Judith C. Baer, Ph.D.
Am J Psychiatry 2010;167:298-304. 10.1176/appi.ajp.2009.09040553
I cite from the conclusion:
"The DSM-V Task Force should consider eliminating the criterion and explore alternative ways to identify false positives in the diagnosis of depression. The criterion's status for other disorders should be evaluated on a disorder-by-disorder basis because the diagnostic relationship between symptoms and impairment varies across categories."
and further
"This evidence suggests that little or nothing will be lost if the criterion is eliminated in DSM-V, a possibility that should be considered by the Mood Disorders Work Group. New approaches to identifying false positive diagnoses for depression should be explored. Our findings suggest that the criterion might not be needed in some other categories as well."
"The results suggest that different treatment methods may be required for the various syndromes that develop in people who fail to recover from bereavement (e.g., medication for depression symptoms, anxiety management for symptoms of anxiety, and exposure for traumatic grief)."
This suggests that the authors are perfectly comfortable with the use of medication for those who have long term problems with bereavement. A significant number of the study participants, 25.2% met the DSM IV definition of depressive disorder and 23.3% were using antidepressants. At best, their point is that there should be a more specific framework for bereavement related mood disorders, so that would include bereavement even more (not less) tightly into the framework of psychiatric treatment than the DSM 5 suggests.
I can't access the book reference.
The last paper abstract clearly says:
"Further analyses did not support the distinctness between complicated grief and depression, or complicated grief and normal grief. Based on these findings, both further investigation into the validity of complicated grief disorder as a diagnosis and verification of the validity of the diagnostic criteria is warranted before declaring this phenomenon appropriate for inclusion in diagnostic systems. "
So, again, it discourages the distinction of bereavement from grief, which is obviously something the DSM 5 tries to correct.
All in all, it seems that these references are more sympathetic than opposed to the suggested changes in the DSM 5.
I find the 2-week window absurd, even as I have observed others who've dealt with grief much more efficiently than I can. This is a ridiculously arbitrary time frame to expect to conclusively reach any decisive short- or long-term treatment, nor lasting diagnosis.
Familiar with the mental health system's services, I usually do seek help when needed. My pain was/is compounded by trauma, as Dr Joanne eloquently describes, and I am indeed a consumer of pharmacopeia for my MDD. Yet, my beef here is not for myself.
While I get that insurance coverage is ugly and complex, and that when meds are necessary, this will reduce that particular hurdle, it implies too much burden on the aggrieved to fit into a pretty uncomfortable box.
Psychiatry ought to be serving the opposite purpose by recognizing the process as individualized, and much less threatening. Let me tell you, the stigma of a mental disorder is nothing to trivialize. Way too many people fear the notion of "needing help" as some sort of unbearable flaw already. This could further limit beneficial access.
When grief strikes, give it wide berth.
This 2-week space is far too limiting for, what I'm sure is, a majority of people.
The insurance questions are, of course, important to many patients who can not afford these services out of pocket. But they can not and should not drive the technical discussion about the classification of mood disorders. It is important to give both patient and practitioner enough time to develop enough of a relationship for a diagnosis to be made that gives the patient a chance for a successful treatment. IMHO a two week "window" is at the very shortest end of a practical diagnostic time scale for ANY mood disorder and responsible practitioners will chose the appropriate time for a diagnosis and treatment based on the patient's needs.
Some of the religious and certain cults that have declared a war against psychiatry.
1. The responsibility to prove that A=Z should fall on those who are asserting that A=Z. The responsibility does not fall on those who do not agree that A=Z to disprove such an equation.
2. Psychiatric diagnoses, particularly existentially related ones, are subjective - NOT objective- decisions. There is no blood test or fMRI that can diagnose such a condition. Thus, your original proposition is a straw man.
3. There are many such research studies which dispute the both the scientific notion as well as the philosophical notion that grief=depression. I doubt Allen Frances is going to write a dissertation on HP re: this as many others have nearly done so. A simple net search will lead you to those.
4. Thomas Kuhn (1969), Structure of a Scientific Revolution: The assent of the relevant community should trump power structures. We dare not make laws and policies related to women who have been raped or gay marriage without consulting the relevant community. If we do, according to Kuhn, we risk a revolution of sorts. Remember, that is precisely how the absurd dx of homosexuality as a mental disorder was removed from the DSM years ago.
So far we haven't seen even one citation from Dr. Frances, who, as a scientist, should know how to argue with FACTS. So far, he has not.