Good Grief vs. Bad Depression

Reviewing Gary Greenberg's book about depression in the October issue of Reason, I noted his criticism of the grief exception to the definition of "major depression" in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM):

Since everybody gets the blues, psychiatrists need to distinguish between normal sadness and pathological sadness, if only to preserve their own credibility as doctors treating illness. But such line drawing is unavoidably subjective. As Greenberg notes, the official definition of "major depression" excludes people who have experienced the death of a loved one within the previous two months. The American Psychiatric Association (APA) has decreed that 60 days of mourning is appropriate, while 61 is not. Up to the two-month line, you are experiencing normal grief; after that, you are sick.

Not only is the cutoff arbitrary, but so is the decision to count only death as a legitimate excuse for "a period of at least 2 weeks during which there is either depressed mood or a loss of interest or pleasure in nearly all activities." As Greenberg observes, "It's not clear why bereavement is the only exempt condition, why, for instance, misfortunes like betrayal by a lover or severe financial loss or political upheaval or serious illness—or for that matter a noncatastrophe, the slow accretion of life’s difficulties or a loss of faith in one’s government or simply existential despair kindled by an awareness of mortality—do not also spare people from the rolls of the diseased."

As Nick Sibilla mentioned earlier this afternoon, the psychiatrists working on the fifth edition of the DSM have proposed a solution to this problem: ditch the grief exception. The New York Times reports that critics of the change worry about "the potential for considerable false-positive diagnosis and unnecessary treatment of grief-stricken persons." Allen Frances, who oversaw the last revision of the DSM, warns that the new edition "will medicalize normality and that millions of people will get psychiatric labels unnecessarily." Jerome Wakefield, the NYU social work professor who wrote The Loss of Sadness, tells the Times:

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. This would pathologize them for behavior previously thought to be normal.

But isn't that what psychiatrists do? While the grief exception is arbitrary, so is the more general distinction between "normal" sadness and the mental illness called depression. How can judgments about the appropriateness of sadness possibly be objective and scientific? And since a mental disorder is whatever the APA says it is, I'm not sure it even makes sense to warn that a change in a disorder's definition will lead to "false-positive diagnosis."  

For more on this theme, see my 2011 essay. Kenneth Kendler, a member of the DSM-5 Mood Disorder Work Group, defends the new definition of depression here.

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  • "Furious" Styles||

    OT: The three "cults" that make up modern day Republican ideology are Catholicism, Mormonism, and Libertarianism.

    http://freethoughtblogs.com/cu.....lina-vote/

  • ipse dixit||

    Wanna play with my stools?

  • Old Mexican||

    I see a silver lining in this. Yes, Catholicism (2 candidates), Mormonism (one) and Libertarianism (one) have each been termed “cults”.


    "By the imaginary people in my head, that's whom!"

  • cynical||

    By Jack Chick, who was reincarnated as PZ Dumbass.

  • Gojira||

    I used to think psychology was fun, but then I took an arrow to the knee.

  • ||

    2/10 WOULD NOT READ

  • Sparky||

    What's the matter, did someone steal your sweetroll?

  • poetry||

    no it's just an overused joke

    so two weeks ago, goji, come on

  • Joe M||

    And since a mental disorder is whatever the APA says it is, I'm not sure it even makes sense to warn that a change in a disorder's definition will lead to "false-positive diagnosis."

    All of this assumes you're the type of person that goes to a psychiatrist in the first place, which is the clearest indicator of pathology there is.

  • nicole||

    Except that in order to get legal access to drugs a bereaved person should totally be able to take during their bereavement, they will probably have to do just that.

  • sounds real good||

    No, you can get those from your GP, short term, and sometimes even long term. Plenty of people are on anti-depressants long term without ever seeing a psychiatrist. A lot of those people would benefit from seeing a psychiatrist for their med management, as well.

  • ||

    I love it. Feeling bad because your husband or wife died is not a psychological disorder. But wanting modern medicine to change your gender is completely normal.

    My point here is not to say we should lock up those who want to change their sex. But only point out the absurdity of these definitions and how politicized they have become. The gay and the transgendered are a powerful political lobby. So they are guaranteed never to make the list. Distraught widows don't have a political lobby. So they get put on.

  • ||

    Make that "now a psychological disorder".

  • Zeb||

    It's only a disorder if you let someone diagnose you with it.

  • ||

    In Russia illness diagnose you.

  • ipse dixit||

    You're not an alcoholic until you start going to the meetings.

  • Paul||

    I'm like a chocoholic, except for booze.

  • Jerry||

    Gender crossing is on the list and still classified as a mental disease.

  • ||

    I thought they took it off when they took off homosexuality.

  • Zeb||

    If it wasn't a disease, how could they try to force insurance companies to pay for sex change operations?

  • ||

    Homosexuality was removed from the DSM-IV, but Gender Identity Disorder is still listed. As you might expect, its presence is becoming increasingly controversial.

  • Jerry Sandusky||

    I can't wait until GID is normalized. Then we can get down to the really important work of normalizing pederasty.

  • Michael Jackson||

    If only I had lived to see the day ...

  • Jess Asken||

    Is cross dressing classified as a mental disease?

  • Paul||

    Is cross dressing classified as a mental disease?

    Only if you wear those shoes with that top. Two snaps down!

  • sounds real good||

    There is controversy over whether some (male) transvestites who seek sex-change operations are actually psychologically transgendered, or merely heterosexual men who have fetishized the concept of themselves as female sex objects. If they decide you are the latter, you can't get reassignment surgery. Make of it what you will, but I am not kidding.

  • ||

    I'm pretty sure mere "feeling bad" is never a sufficient indicator of clinical depression. There has to be a pretty severe effect on your ability to function mentally.

  • Abdul||

    I think you're right when you get a good doc.

    However, all the financial and other incentives lie on the side of giving the patient a prescription.

  • ||

    See e.g. "drug addiction" that miraculously cures itself when the insurance payments run out.

  • Paul||

    I'm pretty sure mere "feeling bad" is never a sufficient indicator of clinical depression. There has to be a pretty severe effect on your ability to function mentally.

    This is 100% correct. It's the care-giver's job to determine that if the person shows up on their door saying that they can't function normally, give me unlimited meds/write a note to my employer telling them I can't go to work but I need to keep getting paid.

  • sounds real good||

    Not just mentally, but in a practical sense in your day to day life.

  • ||

    I get the sense that you feel there's some moral duty for a person to keep the gender s/he was born with? Why? In what way does it affect you? Do you also have a problem with people who get nose jobs or hair transplants?

    If a person doesn't want to be the gender they were assigned at conception -- if they feel uncomfortable behaving and living within the expectations for that gender, and want to reinvent themselves the way any other plastic surgery patient desires -- how is that immoral or pathological?

  • Mensan||

    Going strictly by what he wrote above, I don't see where John ever brought up anything about morality in regard to gender identity.

  • ||

    But only point out the absurdity of these definitions and how politicized they have become. The gay and the transgendered are a powerful political lobby. So they are guaranteed never to make the list.


    He implied that the only reason transgendered people aren't labeled some kind of crazy is that they have a powerful political lobby. IOW, he implied that in a just world, where all influences on the psychosis definitions were equal, those who identify as transgendered would and should probably be considered mentally ill.

  • Mensan||

    Which has absolutely nothing to do with morality.

  • Mensan||

    Also, regardless of what John or you or I think about a just world, in this world transexual people are considered to be mentally ill.

  • hobo's odor eater||

    how is that immoral

    It ceases to be moral as soon as anyone else, in any way, has to pay for it. It is also immoral if it consumes resources that would otherwise be applied in a less frivolous way.

    or pathological

    If you don't understand how using surgery and hormone treatments to play dress up is an indication that something is seriously wrong, then no one will be able to explain it to you.

    Any behavior can be excused by demanding that an explanation for why it is immoral or pathological be given and then rejecting the explanation. Yet, all societies maintain standards of behavior. Currently, most people in the U.S. consider getting a sex change operation to be a pretty f'cked thing to do and something that should never be included in any insurance coverage. I don't see any good reason for that to change. If you are so unhappy with yourself that you want to get yourself surgically mutilated, go ahead, knock yourself out. But don't expect anyone else to pay for it or tell you how wonderful it is that you did so.

  • Coeus||

    It ceases to be moral as soon as anyone else, in any way, has to pay for it.

    Yes.

    It is also immoral if it consumes resources that would otherwise be applied in a less frivolous way.

    No. Sell that utilitarian shit to the tourists, we ain't buying it here.

  • Nurse Cratchett||

    "I sorry, Mr. Mendez. You will have to wait for that open heart surgery, even though the wait may result in your death. The operating room is scheduled to be used to change someone's genitals instead. We realize that you are willing to pay as much as the other patient, but he has dibs."

    Also, morality vs. legality, etc.

  • Coeus||

    I'd say he should have gone to a hospital with more than one operating room, then. Maybe even one with dedicated emergency services. You know, like basically all of them.

    Dumbass.

  • ||

    You're a fucktard. I never said it was moral for insurance to pay for it, and have never believed that. But anyway...

    If you don't understand how using surgery and hormone treatments to play dress up is an indication that something is seriously wrong, then no one will be able to explain it to you.

    The people I've known who've had this done (including one who is a high-ranking executive where I work) made very clear that things were seriously wrong, and life was pretty much unlivable, before the surgery and hormones. FYI, this is still an elective process and it's still 100% patient-funded; I can't and won't speculate about the future. And before the big knife treatment, surgeons typically require the patient to live for a year in the opposite gender, cross-dressing, using the other restroom, dating as if they were already the other gender, etc.

    Nature does not make 100% perfect things. Deformities, abnormalities, hermaphroditism...shit happens. People end up being born some way that they later want to fix, and as long as they've got the cash, I say may the force be with 'em.

    Currently, most people in the U.S. consider getting a sex change operation to be a pretty f'cked thing to do

    Citation? You mean you think it's a pretty f'cked thing to do, let's be honest. Some of us really don't care how our neighbors reinvent themselves as long as they don't cause others harm or loss. It's Adam and Steve as long as Adam wants to be Adam and Steve wants to be Steve. People own their own lives and genders in this country. The opinions of fucktards like you, who otherwise wouldn't care whether their neighbors live or die but suddenly need to condemn them for changing their own bodies to suit themselves, are worthless.

  • hobo's odor eater||

    FYI, this is still an elective process and it's still 100% patient-funded;

    Bullshit. There was a story years ago about prisoners in the NY prison system getting hormone treatments and there are insurance policies that pay for crap like "gait classes" and pre-op counselling. I know because I was included in a group policy that offered such rot along with things like boner pills. Of course, it was in an academic setting. I am sure you are aware that there is a vigorous effort to get more mental health coverage tacked on to health insurance policies even though many people would never go to see a shrink. If Obamacare isn't repealed, it is a sure bet that radical leftist priorities like paying for gender reassignment will be required as part of any health insurance offering.

    Citation? You mean you think it's a pretty f'cked thing to do

    I would give you a citation, but, of course, the media and the political class doesn't poll people about things like that since the results would be so adverse to their agenda. I feel very confident in asserting that most Americans think that sex changes are f'ed up. Hell, most Americans don't even support gay marriage.

    you, who otherwise wouldn't care whether their neighbors live or die

    Citation? I also like your unlibertarian, collectivist notion of caring for your neighbors - refreshing.

    need to condemn them

    I'm not condemning trannies or anyone else. I'm just saying they are mentally f'ed up. Am I allowed to have my own opinion in your world?

  • sounds real good||

    If you are disabled and on Medicare you can get one, provided you convince the psychs you really are transgendered.

  • ||

    "It's not clear why bereavement is the only exempt condition, why, for instance, misfortunes like ... a loss of faith in one’s government ... do not also spare people from the rolls of the diseased."

    [Elipsis for clarity]

    If "loss of faith in one's government" is considered a cause for clinical depression, I should be damned near suicidal by now.

  • BakedPenguin||

    It was a subtle way of saying libertarians are crazy.

  • T||

    We all mad here.

  • Sparky||

    I see what you did there.

  • Zeb||

    How about this. People who think that they need treatment for their mental health can find whatever treatment they think is necessary. I don't really see how the definitions of disorders in the DSM are useful at all. Giving a collection of symptoms a name doesn't do anything to treat the symptoms.

  • ||

    It employs psychiatrists.

  • Barely Suppressed Rage||

    It employs psychiatrists.

    And pharmaceutical companies, who sell you pills that have side effects arguably worse than the thing they're supposed to be treating.

  • Mensan||

    For example (I just happened to have Davis's Drug Guide on my desk):

    sertraline (ser-tra-leen)
    Zoloft

    Classification
    Therapeutic: antidepressants
    Pharmacologic: selective serotonin reuptake inhibitors (SSRIs) ...

    Adverse Reactions/Side Effects
    CNS:
    NEUROLEPTIC MALIGNANT SYNDROME, SUICIDAL THOUGHTS, dizziness, drowsiness, fatigue, headache, insomnia, agitation, anxiety, confusion, emotional lability, impaired concentration, manic reaction, nervousness, weakness, yawning. EENT: pharyngitis, rhinitis, tinnitus, visual abnormalities. CV: chest pain, palpitations. GI: diarrhea, dry mouth, nausea, abdominal pain, altered taste, anorexia, constipation, dyspepsia, flatulence, increased appetite, vomiting. GU: sexual dysfunction, menstrual disorders, urinary disorders, urinary frequency. Derm: increased sweating, hot flashes, rash. F and E: hyponatremia. MS: back pain, myalgia. Neuro: tremor, hypertonia, hypoesthesia, paresthesia, twitching. Misc: SEROTONIN SYNDROME, fever, thirst.
  • Anacreon||

    Most of us physicians who see mentally ill patients think the DSM is absolute bullshit and base very little of what we do on it. But it isn't that important anyway, only lay people get all worked up about it -- it is really only used for diagnosis codes that go on billing forms (and the diagnosis doesn't change the billing, billing is related to time spent). All medicine has billing codes, the DSM is the psychiatrist's part of ICD-9.

  • ||

    No, but it might get you a medical marijuana card in some states.

  • Barry O||

    And then I'll arrest yo' ass

  • Student of the passing scene||

    That's just sick.

  • Jerry||

    And who will pay for that treatment?

  • Obama||

    And who will pay for that treatment?

    Cost reductions will.

  • ipse dixit||

    "I don't really see how the definitions of disorders in the DSM are useful at all."

    It's how insurance companies determine coverage, so it's a pretty big deal.

  • Zeb||

    "Big Deal" and useful do not always coincide.

  • FTFY||

    Giving a collection of symptoms behaviors a name

    Call a collection of behaviors a "syndrome"; blur the distinction between a "syndrome" and a disease. Repeat several dozen times and you have the modern mental health industrial complex.

  • Another Phil||

    Thoughts and feelings are not behaviors. Calling them such does make it easier to dismiss psychology completely though.

  • Dan||

    An estimated 8 to 10 million people lose a loved one every year

    The other 310 million of us lose loved ones less than once every year.

  • ||

    Well, Newt Gingrich seems to manage to lose a loved one fairly regularly.

  • T||

    I dunno, they seem to be able to find him again.

  • ||

    IF they are giving interviews to ABC, can they really be said to be "lost"?

  • ||

    If they are giving interviews to ABC, they are truly 'Lost'.

  • BakedPenguin||

    I dunno, they seem to be able to find him again.

    The question is, why would they want to? Mental illness?

  • Scruffy Nerfherder||

    I laughed

  • ||

    I know a few students at this place who've lost a grandparent every semester (usually right before an exam), so apparently there are such unfortunate people.

  • Zeb||

    If they can keep that going for 4 years, I'll be really impressed.

  • Divorce-Ridden America||

    Easily done.

  • Zeb||

    Oh yeah. DO people count those as grandparents (I suppose if it gets you out of an exam)?

  • Mensan||

    I was under the impression that grandparents weren't a close enough relative to count as an excused absence.

    I'm basing that off the emergency leave requirements when I was in the Army. The death of a grandparent only qualified if that grandparent had been in loco parentis status.

  • ||

    This makes me sad. I'd better set up an appt. with my shrink to talk about it.

  • Old Mexican||

    How can judgments about the appropriateness of sadness possibly be objective and scientific?


    Easily, just follow this formula:

    IF I determine this person to be sad by X, and prescribe Y, I line my pockets with Z bucks.

    See? Scientific!

  • ||

    Part of the problem is the binary classification system, that you either have an illness or don't. It is a continuum and they should treat it as such.

  • Well, ...||

    ... yes and no.

  • Coeus||

    It is a continuum and they should treat it as such.

    Agreed.

  • ||

    So, you will be up to 95% of your dose today?

  • Zeb||

    This seems to be the answer. Depression is a real problem for some people. A clear line does not need to be drawn between depressed and not depressed in order to try to help these people.

  • Paul||

    It is a continuum and they should treat it as such.

    Not entirely. There's evidence that there are actual mental conditions that are diseases that aren't on a continuum, any more than Fibromyalgia is on a continuum.

    Now you may return to your regularly scheduled bitch-fest about whether alcoholism is a disease or not.

  • Coeus||

    Fibromyalgia is like IBS. It's a catch-all for something (and probably several things) we don't really know much about. Not really a good example.

  • Mensan||

    This. Fibromyalgia is like chronic fatigue syndrome. It's a diagnosis of exclusion. It means that tests for everything came back negative.

  • Paul||

    Apologies. I meant Cystic Fibrosis. I'm not sure where my brain was.

  • Gun-Grabbing Politician||

    millions of people will get psychiatric labels unnecessarily

    "Unnecessarily", my ass.

  • ipse dixit||

    I dated a woman who was diagnosed as having borderline personality syndrome (multiple-personality disorder lite). All they did was keep trying different meds, which screwed her up even more.

  • Old Mexican||

    Re: Ipse dixit,

    My wife also suffers from a severe personality disorder, which can only be treated by giving her jewelry, a fancy dinner and by putting away the clean dishes from the dishwasher. Go figure.

  • ||

    Comment of the day!!

  • Barely Suppressed Rage||

    My wife comes down with a severe personality disorder about every four weeks. It lasts about 4-5 days.

  • hansen||

    Don't worry, it's just a phase she's going through - a 30 year long phase.

  • Scruffy Nerfherder||

    Run man run!

  • o3||

    ipse - most women are effed-up in the head & their pill bottles are a stark reminder. >its just that guys convince themselves that THEIR woman is soo diff

  • Anacreon||

    Borderline PD has nothing to do with multiple-personality disorder. In fact, there is actually no such thing as multiple personality disorder, it was just a trendy faux diagnosis in the 90's that has been long discredited.

  • Mensan||

    Borderline personality disorder is unstable erratic emotions, and very poor impulse control. And dissociative identity disorder (multiple personalities) doesn't actually exist. It was just the popular diagnosis after Sybil was published in the '70s.

  • Mensan||

    note to self: Read down the thread before commenting.

  • Coeus||

    Regardless of the reason for the depression, shrooms are the best medicine. They work for far more people than the prescription drugs, and one use can have positive effects on mood for months.

  • Old Mexican||

    Re: Coeus,

    There's nothing that a good blowjob can't cure. I mean it.

  • OM's Doctor||

    ** scribbles something in official medical record **

  • ||

    Even a mediocre one is worth a shot, right?

  • Coeus||

    There's nothing that a good blowjob can't cure. I mean it.

    Now then, Old Mex, I'm flattered, don't get me wrong, but I don't really think of you that way.

  • Barely Suppressed Rage||

    Yeah, unfortunately, the qualifier there is "good". Doesn't help us long-married guys to much. Can't even get a lousy one, for pete's sake.

  • T||

    I'm willing to bet it wouldn't do shit for my pneumonia.

    And I'm still crazy, so they obviously don't help that, either.

  • Scruffy Nerfherder||

    Still worth the old college try...

  • Mensan||

    T, OM meant receiving one.

  • T||

    You figured that out all by yourself? Mensan, indeed.

  • Scruffy Nerfherder||

    Any evidence that they work for migraines?

  • Zeb||

    I don't know about shrooms, but small doses of LSD have shown some promise in treating migraines and cluster headaches.

  • Scruffy Nerfherder||

    Hmmmmmm......

    I wonder if can be used as a preventative and not just an abortive treatment.

  • Paul||

    I don't know about shrooms, but small doses of LSD have shown some promise in treating migraines and cluster headaches.

    My mind almost inserted clusterfucks in your statement when I read it. My first thought was to get it in the drinking water served to government buildings, STAT.

  • Tim||

    Entirely plausible, LSD is an ergot derivative. Other ergot derivative have long been used for that.

  • Coeus||

    Actually, If I know I'm getting a migraine, an orgasm can stave it off for 30 minutes to an hour.

  • Scruffy Nerfherder||

    Unfortunately, it works the opposite for me, just aggravates it. It has to do with muscle tightening in the neck and shoulders.

  • Coeus||

    Yeah, for me, if it isn't done right at the beginning, the attempt makes it worse and it becomes too distracting to get there.

  • Coeus||

    Have you figured out your precursors yet? My main one turned out to be hops.

  • Scruffy Nerfherder||

    C2 vertebra is the main culprit. It compresses a nerve that triggers the migraine. Based on the overall level of compression/stimulation, various other things can trigger a migraine as well. Port wine is definitely one of them.

  • Coeus||

    Maybe sulfites, then?

  • Coeus||

    Oh, you meant shrooms. No, not that I've read about. Never had them on hand to try at the time. Might be worth a try.

  • Mensan||

    I'm just glad to see that Frances used the word normality rather than the too frequently used etymological abomination normalcy.

  • The Ghost of Warren G. Harding||

    "Normalcy" is the new "normality".

  • Charlie Brown||

    Good Grief!

  • I beg of you||

    Let language live.

  • I beg of you||

    That was for you, Mensan.

  • Mensan||

    In almost all other cases I have no problem with that. It's really only normalcy that bothers me.

    That, and when lying statists try to change the definitions of the words in the "living" Constitution.

  • Charles Manson||

    Normalcy bothers me too.

  • Scruffy Nerfherder||

    Let's face it. The APA is just giving people what they want. Most people want to be considered a "victim" of something, whether it be circumstance, genetics, microaggression, etc....

    I hate that we've become a nation of whiners and self-pitying losers looking for our next handout because we "deserve" it. But I can't really blame the APA for filling the needs of the market. People want excuses, the APA is selling them.

  • official historian||

    In days of yore, people in distress were taught to go to their friends, family and clergy for help. They were told that they could improve their relationships and their lives by trying to follow society's rules, that is, they were told that their problems were mostly caused by their own behavior which they needed to change. Nowadays, mental health "professionals" make a good living by telling distressed people that there is nothing wrong with them, but that society is to blame. Screwed-up people are catered to, told what they want to hear. Is it any wonder that no one is held responsible for anything anymore?

  • Scruffy Nerfherder||

    Whether or not the individual or society or genetics is to blame, the next step of suggesting that society owes you something for your pain is the truly offensive part. We've gone far beyond the concept of compensation for direct harm to this wonderland where you're owed something just because you exist.

  • ||

    I'll send you my bill.

  • ||

    Well, historian, because you made those assertions then they must be true.

  • official historian||

    It's not my fault that you don't understand what I wrote.

  • ||

    Why don't you help me out then?

  • T||

    You need to see your therapist for help, cap l. Isn't that what he just said?

  • ||

    I don't know, I just don't know. I just need my medication...WHERE ARE MY FUCKING PILLS, MAN!!!

    I'm fine, really, sorry about that.

    I cannot figure out if historian is good at satire or if he's simply and asshole...maybe both...I'll never suss this out

    WITHOUT

    MY

    FUCKING

    PILLS

    !!!!!!!GIMMMMMMMMMMMEEE!!!!!!!!!!!!

  • Mensan||

    I thought in days of yore they were told that they were possessed by demons, or cursed by witches, and the methods of remedy often were torture and death.

  • ||

    This is my field, so I feel compelled to comment. The DSM is very specific in letting practitioners know that all normative causal factors must be ruled out before any diagnosis can take place. So for example, you can't get a diagnosis for Major Depressive Disorder unless you meet all the criteria listed, and that the symptomology (ie criteria for diagnosis) is not due to a normative event like death, divorce, natural disaster, combat stress, etc. Mainly because if you have experienced these events they will treat you for either grief or PTSD. Are there psychiatrists, psychologists, and doctors who don't know how to diagnose? Oh, yeah. They don't want to listen to your problems (even though that is their job) so they focus on giving out happy pills (and getting their kick-back from the pharmacutical industry). Since they get paid either way, guess which way they usually go?

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