When the American Psychiatric Association unveils a proposed new version of its Diagnostic and Statistical Manual of Mental Disorders, the bible of psychiatric diagnoses, it expects controversy. Illnesses get added or deleted, acquire new definitions or lists of symptoms. Everyone from advocacy groups to insurance companies to litigators — all have an interest in what’s defined as mental illness — pays close attention. Invariably, complaints ensue.
“We asked for commentary,” said David Kupfer, the University of Pittsburgh psychiatrist who has spent six years as chairman of the task force that is updating the handbook. He sounded unruffled. “We asked for it and we got it. This was not going to be done in a dark room somewhere.”
But the D.S.M. 5, to be published in May, has generated an unusual amount of heat. Two changes, in particular, could have considerable impact on older people and their families.
First, the new volume revises some of the criteria for major depressive disorder. The D.S.M. IV (among other changes, the new manual swaps Roman numerals for Arabic ones) set out a list of symptoms that over a two-week period would trigger a diagnosis of major depression: either feelings of sadness or emptiness, or a loss of interest or pleasure in most daily activities, plus sleep disturbances, weight loss, fatigue, distraction or other problems, to the extent that they impair someone’s functioning.
Traditionally, depression has been underdiagnosed in older adults. When people’s health suffers and they lose friends and loved ones, the sentiment went, why wouldn’t they be depressed? A few decades back, Dr. Kupfer said, “what was striking to me was the lack of anyone getting a depression diagnosis, because that was ‘normal aging.’” We don’t find depression in old age normal any longer.
But critics of the D.S.M. 5 now argue that depression may become overdiagnosed, because this version removes the so-called “bereavement exclusion.” That was a paragraph that cautioned against diagnosing depression in someone for at least two months after loss of a loved one, unless that patient had severe symptoms like suicidal thoughts.
Without that exception, you could be diagnosed with this disorder if you are feeling empty, listless or distracted, a month after your parent or spouse dies.
“D.S.M. 5 is medicalizing the expected and probably necessary process of mourning that people go through,” said Allen Francis, a professor emeritus at Duke who chaired the D.S.M. IV task force and has denounced several of the changes in the new edition. “Most people get better with time and natural healing and resilience.”
If they are diagnosed with major depression before that can happen, he fears, they will be given antidepressants they may not need. “It gives the drug companies the right to peddle pills for grief,” he said.
An advisory committee to the Association for Death Education and Counseling also argued that bereaved people “will receive antidepressant medication because it is cheaper and ‘easier’ to medicate than to be involved therapeutically,” and noted that antidepressants, like all medications, have side effects.
“I can’t help but see this as a broad overreach by the APA,” Eric Widera, a geriatrician at the University of California, San Francisco, wrote on the GeriPal blog. “Grief is not a disorder and should be considered normal even if it is accompanied by some of the same symptoms seen in depression.”
But Dr. Kupfer said the panel worried that with the exclusion, too many cases of depression could be overlooked and go untreated. “If these things go on and get worse over time and begin to impair someone’s day to day function, we don’t want to use the excuse, ‘It’s bereavement — they’ll get over it,’” he said.
The new entry for major depressive disorder will include a note — the wording isn’t final — pointing out that while grief may be “understandable or appropriate” after a loss, professionals should also consider the possibility of a major depressive episode. Making that distinction, Dr. Kupfer said, will require “good solid clinical judgment.”
Initial field trials testing the reliability of D.S.M. 5 diagnoses, recently published in The American Journal of Psychiatry, don’t bolster confidence, however. An editorial remarked that “the end results are mixed, with both positive and disappointing findings.” Major depressive disorder, for instance, showed “questionable reliability.”
In an upcoming post, I’ll talk more about how patients might respond to the D.S.M. 5, and to a new diagnosis that might also affect a lot of older people — mild neurocognitive disorder.
Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”
