Psychiatric disorders definitions to be revised

By Dr. Ananya Mandal, MDJan 26 2012

The definition of depression is proposed to be changed and now the diagnosis would characterize grieving as a disorder and greatly increase the number of people treated for it.

The criteria for depression are being reviewed by the American Psychiatric Association, which is finishing work on the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders, or DSM, the first since 1994. The manual is the standard reference for the field, shaping treatment and insurance decisions, and its revisions will affect the lives of millions of people for years to come.

The new report, by psychiatric researchers from Columbia and New York Universities, argues that the current definition of depression — which excludes bereavement, the usual grieving after the loss of a loved one — is far more accurate. If the “bereavement exclusion” is eliminated, they say, “there is the potential for considerable false-positive diagnosis and unnecessary treatment of grief-stricken persons.” Drugs for depression can have side effects, including low sex drive and sleeping problems.

Under the current criteria, a depression diagnosis requires that a person have five of nine symptoms — which include sleeping problems, a feeling of worthlessness and a loss of concentration — for two weeks or more. The criteria make an explicit exception for normal grieving, which can look like depression. But the proposed diagnosis of depression has no such exclusion, and in the new study, Jerome C. Wakefield of New York University and Dr. Michael First of Columbia concluded that the evidence was not strong enough to support the change. “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,” said Dr. Wakefield, author of “The Loss of Sadness.” “This would pathologize them for behavior previously thought to be normal.”

But experts who support the new definition say sometimes grieving people need help. “Depression can and does occur in the wake of bereavement, it can be severe and debilitating, and calling it by any other name is doing a disservice to people who may require more careful attention,” said Dr. Sidney Zisook, a psychiatrist at the University of California, San Diego.

The revised report would have changes in other disorders as well including new diagnoses that include “binge eating disorder,” “premenstrual dysphoric disorder” and “attenuated psychosis syndrome.” The clashes typically revolve around subtle distinctions that are often not readily apparent to those unfamiliar with the revision process. If a person does not meet precise criteria, then the diagnosis does not apply and treatment is not covered. This makes the accuracy of the revisions crucial and debate prone.

An Oct. 22 letter critical of the changes, sponsored by units of the American Psychological Association in Washington, was signed by more than 10,800 people, including psychologists, psychiatrists, counselors, and community activists. The British Psychological Association, based in Leicester, England, sent a similar letter in June 2011. The letters identify changes such as the one affecting ADHD, or Attention Deficit Hyperactivity Disorder, a long- identified illness that involves hyperactive people who have difficulty staying focused and controlling behavior, according to the National Institutes of Health in Bethesda, Maryland. In the present manual, a diagnosis for ADHD requires six symptoms to be identified in adults, including some present before age 7. The new manual requires only four to be identified and the disorder no longer must present itself in childhood.

“The world has changed” since the last revision, in 1993, said Dr. James H. Scully Jr., chief executive of the psychiatric association. “We’ve got electronic media around the clock, and we’ve made drafts of the proposed changes public online, for one thing. So anybody and everybody can comment on them, at any time, without any editors.”

“What I worry about most is that the revisions will medicalize normality and that millions of people will get psychiatric labels unnecessarily,” said Dr. Allen Frances, who was chairman of the task force that revised the last edition. Dr. Frances, now an emeritus professor at Duke University, has been criticizing the current process relentlessly in blog posts and e-mails. Dr. Robert L. Spitzer, who oversaw revision of the third manual in 1980, has also voiced concerns, as have the American Counseling Association, the British Psychological Society and a division of the American Psychological Association.

“There’s already overuse of these drugs in children and adolescents, and having this vague diagnosis, regardless of its intent, will only increase misuse in this vulnerable population,” said Dr. Peter J. Weiden, director of the psychosis treatment program at the University of Illinois at Chicago.

For now, these revisions are still in play; the completed manuscript is due for release in December. Recent findings in genetics show that nature does not respect psychiatric categories — many different disorders seem linked to some of the same genetic glitches. Already a federal agency, the National Institute of Mental Health, has set up its own independent effort to classify mental disorders, called Research Domain Criteria, which will not be based on existing categories.

One in 5 Americans experienced some form of mental illness this year, according to a report this month by the U.S. Substance Abuse and Mental Health Services Administration, using the manual’s current criteria to develop the data. According to the National Institutes of Mental Health, costs in this area rose 63 percent to $57.5 billion in 2006 from a decade earlier. Critics say those figures may rise quickly if the new manual is approved as proposed.