Saturday, August 21, 2010

Doctor and Patient - Talking to Patients After a Medical Error - NYTimes.com

One afternoon, I overheard a nurse asking another physician how she was feeling. The physician, a young woman known throughout the hospital for her cheery disposition and sunny bedside manner, looked ashen. She smiled weakly in response and insisted that nothing was wrong.

"She's lying," the nurse whispered to me as the doctor walked away. "She's upset because risk management wouldn't let her go to that patient's funeral."

That the optimistic young physician would grieve following a patient's death hardly surprised anyone. We had all seen her go through the death of a patient before: she worked in a specialty where such loss was relatively common, yet she fearlessly continued to develop deep relationships with those she cared for. However, as the nurse so perceptively noted that afternoon, what was more difficult for her to bear this time was not the loss but the constraint imposed on the relationship afterward.

Her patient had died in the hospital a week earlier. In conversations in the hallways and clinics, other doctors and nurses combed through the facts of the event hoping to find some detail — a physiological oddity, an honest misunderstanding, even an error — that could help prevent the same thing from happening to our patients in the future.

But then rumors that the family was considering a lawsuit began to make the rounds. Soon afterward, administrators from risk management, the department of the hospital devoted to improving safety, began warning us not to talk about the case — not to one another, not to the news media and, most of all, not to the family. It was not hard to understand why under this new order of silence attending a patient's funeral might be discouraged.

Several weeks later, I ran into my colleague once more and asked if she had heard anything about the patient's family. "Yes," she said lowering her voice. She pulled me over to a quiet end of the hallway and recounted a recent phone conversation with the patient's mother. Then she took a deep breath and began grinning broadly. "I know the hospital and the lawyers and the other doctors might disagree with what I did, but I had to talk to the family," she said. "I just couldn't abandon them."

Despite the best efforts of health care professionals, bad things can happen in hospitals. Up until more recently, when errors occurred, the scenario that played out was always the same. Clinicians, devastated but fearful of litigation, would shut down. Patients and their families, grieving but desperate to make sense of the event, would find that their doctors and nurses were no longer responsive or available. Eventually, the most important relationship in health care, that between patient and doctor, would cede to the most adversarial one, that between plaintiff and defendant.

In the late 1980s, one hospital system, the Veterans Affairs Medical Center in Lexington, Ky., decided to try another approach to medical mistakes. Doctors there eventually published a paper describing their "humanistic risk management policy." It included early review of the events that took place, full disclosure to patients of accidents or errors, fair compensation for injuries and ongoing attention to the relationship between clinicians and patients. And it appeared to decrease liability claims and costs.

Encouraged by these early results and by emerging data linking open disclosure with patient satisfaction, quality of care and improved overall safety, a few other intrepid health care systems across the country began to experiment with similar programs.

Few at the time could argue against the benefits to patients of open disclosure. But in the years since, one question has remained: are these policies also beneficial to physicians, many of whom are already struggling just to get their work done?

According to a study released this week in The Annals of Internal Medicine and the experience of one of the early-adopter institutions, the answer appears to be yes.

Since 2001, the University of Michigan Health System has handled patient injuries by initiating discussions with patients and families, conducting internal investigations and offering apologies with offers of compensation should those investigations reveal medical errors. To examine the repercussions of such an open disclosure with compensation policy, researchers analyzed the number of claims and lawsuits filed against the hospital system between 1995 and 2007, comparing data from before and after the policy took effect.

Contrary to fears that such transparency might worsen litigation, the researchers found that there were actually fewer lawsuits and claims after the hospital began its disclosure with compensation program. Moreover, the hospital system's liability costs for lawsuits, patient compensation and legal fees dropped, and claims in general were resolved faster than ever before.

More ...

http://www.nytimes.com/2010/08/19/health/19chen.html?ref=views&pagewanted=print

U.S. Inaction Lets Look-Alike Tubes Kill Patients - NYTimes.com

Thirty-five weeks pregnant, Robin Rodgers was vomiting and losing weight, so her doctor hospitalized her and ordered that she be fed through a tube until the birth of her daughter.

But in a mistake that stemmed from years of lax federal oversight of medical devices, the hospital mixed up the tubes. Instead of snaking a tube through Ms. Rodgers's nose and into her stomach, the nurse instead coupled the liquid-food bag to a tube that entered a vein.

Putting such food directly into the bloodstream is like pouring concrete down a drain. Ms. Rodgers was soon in agony.

"When I walked into her hospital room, she said, 'Mom, I'm so scared,' " her mother, Glenda Rodgers, recalled. They soon learned that the baby had died.

"And she said, 'Oh, Mom, she's dead.' And I said, 'I know, but now we have to take care of you,' " the mother recalled. And then Robin Rodgers — 24 years old and already the mother of a 3-year-old boy — died on July 18, 2006, as well. (She lived in a small Kansas town, but because of a legal settlement with the hospital, her mother would not identify it.)

Their deaths were among hundreds of deaths or serious injuries that researchers have traced to tube mix-ups. But no one knows the real toll, because this kind of mistake, like medication errors in general, is rarely reported. A 2006 survey of hospitals found that 16 percent had experienced a feeding tube mix-up.

Experts and standards groups have advocated since 1996 that tubes for different functions be made incompatible — just as different nozzles at gas stations prevent drivers from using the wrong fuel.

But action has been delayed by resistance from the medical-device industry and an approval process at the Food and Drug Administration that can discourage safety-related changes.

Hospitals, tube manufacturers, regulators and standards groups all point fingers at one another to explain the delay.

Hospitalized patients often have an array of clear plastic tubing sticking out of their bodies to deliver or extract medicine, nutrition, fluids, gases or blood to veins, arteries, stomachs, skin, lungs or bladders.

Much of the tubing is interchangeable, and with nurses connecting and disconnecting dozens each day, mix-ups happen — sometimes with deadly consequences.

"Nurses should not have to work in an environment where it is even possible to make that kind of mistake," said Nancy Pratt, a senior vice president at Sharp HealthCare in San Diego who is a vocal advocate for changing the system. "The nuclear power and airline industries would never tolerate a situation where a simple misconnection could lead to a death."

More ...

http://www.nytimes.com/2010/08/21/health/policy/21tubes.html?th&emc=th

Friday, August 20, 2010

Palliative Care Extends Life of Lung Cancer Patients, Study Finds - NYTimes.com

In a study that sheds new light on the effects of end-of-life care, doctors have found that patients with terminal lung cancer who began receiving palliative care immediately upon diagnosis not only were happier, more mobile and in less pain as the end neared — but they also lived nearly three months longer.

The findings, published online Wednesday by The New England Journal of Medicine, confirmed what palliative care specialists had long suspected. The study also, experts said, cast doubt on the decision to strike end-of-life provisions from the health care overhaul passed last year.

"It shows that palliative care is the opposite of all that rhetoric about 'death panels,' " said Dr. Diane E. Meier, director of the Center to Advance Palliative Care at Mount Sinai School of Medicine and co-author of an editorial in the journal accompanying the study. "It's not about killing Granny; it's about keeping Granny alive as long as possible — with the best quality of life."

In the three-year study, 151 patients with fast-growing lung cancer at Massachusetts General, one of the nation's top hospitals, were randomly assigned to get either oncology treatment alone or oncology treatment with palliative care — pain relief and other measures intended to improve a patient's quality of life. They were followed until the end of 2009, by which time about 70 percent were dead.

Those getting palliative care from the start, the authors said, reported less depression and happier lives as measured on scales for pain, nausea, mobility, worry and other problems. Moreover, even though substantially fewer of them opted for aggressive chemotherapy as their illnesses worsened and many more left orders that they not be resuscitated in a crisis, they typically lived almost three months longer than the group getting standard care, who lived a median of nine months.

Doctors and patients "traditionally see palliative care as something extended to a hospitalized patient in the last week of life," said Dr. Jennifer S. Temel, an oncologist and author of the paper. "We thought it made sense to start them at the time of diagnosis. And we were thrilled to see such a huge impact. It shows that palliative care and cancer care aren't mutually exclusive."

Dr. Atul Gawande, a Harvard Medical School surgeon and writer who just published a long article in The New Yorker about hospitalized patients' suffering before death, called the study "amazing."

"The field was crying out for a randomized trial," he added.

Although the study could not determine why the patients lived longer, the authors and other experts had several theories: depression is known to shorten life, and patients whose pain is treated often sleep better, eat better and talk more with relatives. Also, hospitals are dangerous places for very sick people; they may get fatal blood infections, pneumonia or bedsores, or simply be overwhelmed by the powerful drugs and radiation attacking their cancer.

Saying the study was "of critical importance," Dr. R. Sean Morrison, president of the American Academy of Hospice and Palliative Medicine, said it was the "first concrete evidence of what a lot of us have seen in our practices — when you control pain and other symptoms, people not only feel better, they live longer."

There is sometimes tension between medical specialties, since surgeons and oncologists often view cancer as a battle, while palliative care specialists are seen as "giving up."

Palliative care typically begins with a long conversation about what the patient with a terminal diagnosis wants out of his remaining life. It includes the options any oncologist addresses: surgery, chemotherapy and radiation and their side effects. But it also includes how much suffering a patient wishes to bear, effects on the family, and legal, insurance and religious issues. Teams focus on controlling pain, nausea, swelling, shortness of breath and other side effects; they also address patients' worries and make sure they have help with making meals, dressing and bathing when not hospitalized.

Hospice care is intensive palliative care including home nursing, but insurers and Medicare usually cover it only if the patient abandons medical treatment and two doctors certify that death is less than six months away.

During the debate over President Obama's 2009 health care bill, provisions to have Medicare and insurers pay for optional consultations with doctors on palliative and hospice care led to rumors, spread by talk-show hosts like Rush Limbaugh and Glenn Beck and by the former vice-presidential candidate Sarah Palin, that the bill empowered "death panels" that would "euthanize" elderly Americans.

Legislators eventually removed the provisions. In practice, Medicare and private insurers do pay for some palliative care, said Dr. Gail Austin Cooney, a former president of the palliative medicine academy. "But it's piecemeal," she said. "The billing is complicated, and for many physicians that's enough of a deterrent to not bother."

Dr. Cooney herself had such care along with surgery and chemotherapy for ovarian cancer in 2008.

"I decided I wanted every drop of chemotherapy they could give me, and it was very painful, dumping the drugs directly into my belly," she said. She needed powerful painkillers, and also chose alternative-medicine options like acupuncture and "energy work" for nausea and fatigue.

"I'm rigid — I had my last chemo treatment on Christmas Eve because I wanted it on the day I was due for it," she said. "But I couldn't have completed the program without the psychosocial support."

Palliative care experts now want to study patients with other cancers, heart disease, stroke, dementia and emphysema. But the National Institutes of Health is under budget pressure, and the other major source of money for medical research, the pharmaceutical industry, has little incentive to study palliative care. This trial was paid for by the American Society of Clinical Oncology and private philanthropy.

"Philanthropists tend to focus on curing cancer," Dr. Temel said. "But we can't ignore people who need end-of-life care."

http://www.nytimes.com/2010/08/19/health/19care.html?ref=general&src=me&pagewanted=print

Books of The Times - Melanie Thernstrom’s ‘Pain Chronicles’ - NYTimes.com

For the fortunate, pain is temporary and finite, with a clear beginning, middle and end. But for more than 70 million Americans, including Melanie Thernstrom, pain is chronic, and the primary reason that they seek medical care. The medical profession has been slow to recognize this development. There is currently one board-certified pain specialist in the United States for every 25,000 patients, she writes in her new book, "The Pain Chronicles." That number, however, is likely to grow as pain is redefined not as a symptom but as a disease that "can eventually rewrite the central nervous system, causing pathological changes to the brain and spinal cord, and ... greater pain."

There have been hundreds of books published in the last decades on pain and its management, but none that combine memoir, scholarly research and journalistic reportage in the way Ms. Thernstrom, the author of two previous books, does. A stellar example of literary nonfiction (parts of which first appeared in The New York Times Magazine), the book recounts the author's own years with chronic pain and the preconceptions she brought to it (including the idea of pain as the price for romantic love); summarizes its social, cultural and medical history; and gives us a reporter's view of state-of-the-art treatment.

The book has a patchwork quilt structure: more than one hundred small captioned patches (or dispatches), organized into five parts and threaded with personal narrative. This invites differently motivated readers to skip or skim. You can chuckle over the aper├žus of poets and philosophers like Aristotle, Coleridge, Dickinson, Sontag, and Foucault in the section entitled "Pain as Metaphor." You can become absorbed, as I was, in the fascinating struggle over the use of anesthesia (and, later, opiates) in "Pain as History," or play voyeur during absorbing clinical vignettes of "Pain as Disease."

Ms. Thernstrom begins with the transformation of the centuries-old mystical disease of consumption, which, in 1882, was finally revealed to be caused by a bacterium. As a result, consumption became tuberculosis — not a curse, not a character weakness, but a disease. Chronic pain, Ms. Thernstrom writes, is currently in the same state of transformation, and because she suffers from an arthritic condition that ranges from irritating to incapacitating, she is bent upon learning the state of the medical art.

She dates the onset of her chronic pain to the day she falls in love with a young academic, the least compellingly drawn of the large cast of characters we meet. They go swimming, and that night she feels an unpleasant burning sensation spread from her neck to her right shoulder, down her right arm to her hand. At first she sees it as "a pointless ache in my neck and shoulders, which I dimly attributed to a structural weakness in my body"; once she realizes that it is chronic, she compares it to "a sour domestic partner — intimate and ugly; a threatening, dirtying, distracting presence, yet one who refused to move out."

A magazine assignment steers her to what became a kind of narrative therapy, a meditation on pain as seen by art, literature, philosophy, religion and science.

Except for a reference to her favorite grandmother, a Christian Scientist, Ms. Thernstrom tells us little of her family's attitudes toward pain. We do, however, reap the rewards of her lifelong prodigious reading, as she investigates the cultural connotations of pain, from the etymology of the word in various languages to its interpretations.

Throughout her narrative physicians are both villains and heroes. Ms. Thernstrom gives us glimpses of the mid-19th-century men (Dr. Henry Bigelow: "Our craft has, once and for all, been robbed of its terrors") who discovered or recognized the efficacy of ether and chloroform, and the surgeons who, at first, opposed their use (Alfred Velpeau: "To escape pain in surgical operation is a chimera").

There are mini-profiles of 21st-century doctors on the frontiers of neurobiology; placebo researchers; and pain specialists who allowed her to sit in on their sessions with patients and interview them afterward. And there are many patients, often eloquent chronic pain sufferers, whose stories complement and contextualize her own.

Although some of them discuss massage and acupuncture, Ms. Thernstrom gives these treatments short shrift and evinces little interest in how Eastern medicine addresses pain. Nor does she provide a judicious evaluation of psychotherapy; she refers to an early "psychoanalysis session, " and doesn't return to the subject. Physical therapy reminds her of dating: "small, futile-feeling gestures that require faith to believe they will eventually lead you somewhere."

But memoir is a subjective form that chooses its own territory and doesn't claim to cover all the bases. What counts is the narrator's voice, interests and sensibility. Melanie Thernstrom is such an engaging and intelligent writer that I remained intrigued with her investigation even as I disagreed with some of her reportorial choices. I cheered as she disentangled romantic from physical pain and found a caring partner. I was dismayed to discover that she found no remedy and that, for the time being, she and millions of others will continue to suffer from chronic pain.

http://www.nytimes.com/2010/08/20/books/20book.html?_r=1

Wednesday, August 18, 2010

More U.S. teens are experiencing hearing loss - latimes.com

Teenagers aren't necessarily tuning out adults; they simply might not be able to hear them.

The proportion of teens in the United States with slighthearing loss has increased 30% in the last 15 years, and the number with mild or worse hearing loss has increased 77%, researchers said Tuesday.

One in every five teens now has at least a slight hearing loss, which can affect learning, speech perception, social skills development and self-image; one in every 20 has a more severe loss.

The authors of the report in the Journal of the American Medical Assn. eliminated ear infections and exposure to loud noises in the environment as causes for the hearing loss, but could not identify a specific cause. A recent Australian study, however, found a 70% increased risk of hearing loss associated with the use of headphones to listen to portable music, and many experts suspect they are the primary cause of hearing loss in teens.

"Personal stereos are the most important change in the culture in the last 15 to 20 years," said Dr. Tommie Robinson Jr., president of the American Speech-Language-Hearing Assn. "Everybody has their own little device now, and how many times have you passed somebody and could hear their music?"

Even the relatively low level of damage found in the study can create problems.

"Just because a hearing loss is slight does not mean it is insignificant, particularly when it is in the high frequencies," said Dr. Alison Grimes, manager of the audiology clinic at Ronald Reagan- UCLAMedical Center.

In English, soft high-frequency sounds such as "s," "f," "th" and "sh" "carry a great deal of meaning, and are very important sounds to be able to discern," Grimes said. But those are the first to be lost, especially in a noisy environment like a classroom. "We know children have more difficulty learning and keeping up academically" when they can't hear well, she added.

Hearing loss can also affect social lives, because the teens may miss parts of conversations and punch lines, or may have to keep asking others to repeat things. "It may seem like they are not in touch, and kids are very aware when someone is a little different," said Dr. Gary C. Curhan of Brigham and Women's Hospital in Boston, a coauthor of the report.

More ...

http://www.latimes.com/news/science/la-sci-teens-hearing-loss-20100818,0,559994.story

Monday, August 16, 2010

Health Blog - Wall Street Journal

Health Blog offers news and analysis on health and the business of health. The blog is written by Katherine Hobson and includes contributions from staffers at The Wall Street Journal, WSJ.com and Dow Jones Newswires.

http://blogs.wsj.com/health/

Chronic Fatigue Syndrome Forums (ME/CFS Forums) at the PHOENIX RISING - Recent Blogs

http://www.forums.aboutmecfs.org/blog.php

Harris Polls > “Cyberchondriacs” on the Rise?

The latest Harris Poll, measuring how many people use the Internet to look for information about health topics, finds that the numbers continue to increase. The Harris Poll first used the word Cyberchondriacs to describe these people in 1998, when just over 50 million American adults had ever gone online to look for health information. By 2005, that number had risen to 117 million. In the new poll, the number of Cyberchondriacs has jumped to 175 million from 154 million last year, possibly as a result of the health care reform debate. Furthermore, frequency of usage has also increased. Fully 32% of all adults who are online say they look for health information "often," compared to 22% last year.

These are some of the results of The Harris Poll of 1,066 adults surveyed by telephone between July 13 and 18, 2010 by Harris Interactive.

Other findings in the new Harris Poll include:

  • While the percentage of adults who go online (79%) has not changed significantly for several years, the proportion of those who are online and have ever used the Internet to look for health information has increased to 88% this year, the highest number ever.
  • Fully 81% of all Cyberchondriacs have looked for health information online in the last month. And 17% have gone online to look for health information ten or more times in the last month. On average, Cyberchondriacs do this about 6 times a month.
  • Very few Cyberchondriacs are dissatisfied with their ability to find what they want online. Only 9% report that they were somewhat (6%) or very (3%) unsuccessful. And only 8% believe that the information they found was unreliable.
  • Just over half (53%) of all Cyberchondriacs report that they have discussed information they found online with their doctors.
  • Half (51%) of all Cyberchondriacs say they have searched for information on the Internet based on discussions with their doctors.
http://www.harrisinteractive.com/NewsRoom/HarrisPolls/tabid/447/mid/1508/articleId/448/ctl/ReadCustom Default/Default.aspx

Neuron Culture - David Dobbs on science, nature, culture

David Dobbs writes features and essays for publications including the Atlantic, the New York Times Magazine, National Geographic, Wired, and Scientific American. Several of his stories have been chosen for leading science anthologies; most recently, his much-discussed feature for the Atlantic, "The Orchid Children," was selected by Jerome Groopman for Ecco/HarperPerennial's Best American Science Writing 2010. He is now writing a book, working title The Orchid and the Dandelion (Houghton Mifflin Harcourt) that further explores the hypothesis he brought to light in his Atlantic story: that the genes and traits that underlie some of our most troublesome mental conditions and behaviors also sometimes generate some of our greatest strengths and accomplishments. 

http://www.neuronculture.com/

Sunday, August 15, 2010

Doctors debate whether hoarding a real mental illness

If the estimates are true, more than one million Canadians may be living the kind of lives Marie Rose lived, until a two-metre high pile of clothes and clutter collapsed on top of her, suffocating her to death.

It took police and her husband 10 hours to find her body.

The Washington State woman’s tragically bizarre death in 2006 was a severe case of hoarding — a condition that could soon be classified an official mental sickness.

“Hoarding disorder” is being recommended for inclusion in the Diagnostic and Statistical Manual of Mental Disorders, or DSM, an enormously influential catalogue used daily by doctors worldwide that is undergoing its first major revision in nearly 20 years.

Should hoarding make it into the manual, 2% to 5% of the Canadian population could be labelled as having a mental illness, according to studies being used to justify creating the new diagnosis.

Proponents say the goal is to increase public awareness, help identify sufferers and stimulate research and the development of treatments that work.

But critics are uneasy, and question who decides when collecting and saving crosses the line from normal human behaviour to pathological.

“The DSM-5 drafters are having a lot of trouble separating eccentricity from illness,” says Edward Shorter, a social historian of medicine at the University of Toronto and author of A History of Psychiatry: From the Era of the Asylum to the Age of Prozac.

“The real problem is psychiatry’s inability to tell us what really does constitute illness — what is disease in psychiatry? — because there are so few objective standards, unlike any other field of medicine,” Mr. Shorter says.

“In psychiatry, the rule of thumb is: If you think you’re sick and I think you’re sick, then you’re sick.”

Under the proposed diagnosed criteria, hoarding is defined as “persistent difficulty discarding or parting with possessions,” regardless of their worth. (Animals aren’t specifically mentioned, but the working group is considering adding them to the proposed criteria. In July, 44 dogs were seized from a feces-covered garage in Gull Lake, Man., owned by a couple that, according to a Winnipeg Free Press report, described themselves as Good Samaritans trying to save the animals from those who had abandoned them.)

Hoarders accumulate stacks of worthless objects that can make homes fire traps and entire rooms unlivable. They hold on to them for comfort, sentimental attachment (many cases start after the death of a loved one) or out of a firm belief that they may come in handy some day.

Hoarders hoard newspapers, magazines, empty food packages, pizza boxes, clothes, Kleenex, plastic bags, car parts, electronic equipment, tools, furniture and — particularly for women — wool, fabric and craft supplies. It starts somewhere — the back of the car, the backyard or the garage — “and it spreads from there,” says Elaine Birchall, an Ottawa social worker who counsels hoarders. Other “life forms” move in, she says — cockroaches, silver fish, mice.

Ms. Birchall was recently involved in a voluntary “clean” where 11 tons of material were removed from a three-bedroom bungalow in Ottawa. There were cans of food dating back to the 1980s.

Hoarding affects all socioeconomic groups and, while those who seek help are overwhelmingly female, some studies suggest men are more affected than women. People become socially isolated.

“They’re ashamed of having people over, it interferes with their relationships with relatives; neighbours might start complaining — it kind of snowballs,” says David Mataix-Cols, an advisor to the working group recommending hoarding be added to the DSM.

The disorder isn’t listed in the current edition, except as one of the criteria for obsessive-compulsive disorder, or OCD.

But the drugs and behaviour therapy used for OCD barely touch hoarders, if at all, researchers say. Nor do hoarders experience intrusive thoughts, images or impulses, says Mr. Mataix-Cols, a senior lecturer in the Institute of Psychiatry at King’s College London.

“They’re not constantly bombarded with unpleasant thoughts about their possessions at all.

“If we call them OCD, and we keep giving them some treatments and we keep failing, we’re not going to get very far.”

He says the idea isn’t to pathologize normal human behaviour.

“Many people have asked, how do we separate the stamp collector who’s a bit eccentric and has millions of stamps” from a pathological hoarder, he says.

The healthy collector, says Mr. Mataix-Cols, “doesn’t feel any distress whatsoever and there’s no interference with everyday life.”

He says the provisional diagnostic criteria are conservative and worded in such a way that only those suffering true distress and impairment would get a hoarding diagnosis.

Dr. Frank Farley isn’t so convinced.

“Don’t do it,” says the Edmonton native and former president of the American Psychological Association.

“The diagnostic bible just gets bigger and bigger. Where’s it headed?” he says.

The current edition lists 357 psychiatric afflictions, up from 128 when the first slim volume was published in 1952.

“Treat hoarding in some other category, rather than creating yet another one that may or may not be valid and extensive enough to have a new category for,” says Dr. Farley.

He says the quoted prevalence rates “need to be taken with a grain of salt. Nobody is testing the whole country. They’re projections based on small samples. “

“You don’t want to create a whole sort of science on a few unusual cases,” says Dr. Farley.

“The drug companies will start creating drugs allegedly specifically for ‘hoarding disorder’ and away we go, we’re off to the races one more time.”

http://www.nationalpost.com/news/Doctors+debate+whether+hoarding+real+mental+illness/3401981/story.html

Op-Ed Contributor - Good Grief - NYTimes.com

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.