Showing posts with label grief. Show all posts
Showing posts with label grief. Show all posts

Monday, March 21, 2022

Prolonged Grief Disorder - A Few Comments



The New York Times came out with an article on prolonged grief disorder.  I thought I would write about it because in some ways it is a continuation of the criticism that started with the DSM-5 release in 2015.  The response to that piece is one of the most read articles on thisblog. As I pointed out in that article and several since, the release of the DSM-5 has been a predicted non-event. There were no scandalous developments based on releasing a document that hardly anyone reads and is not even owned by most of the people who prescribe medications for psychiatric indications – primary care physicians.

The new piece based on the release of DSM5-TR is much more balanced.  A well-known psychiatric researcher Katherine Shear, MD is quoted as well as an epidemiologist Holly Prigerson, PhD who discovered data supportive of the diagnosis and studied the reliability and validity.  Paul Appelbaum, MD is the head of the committee to include new diagnoses in the manual and he also explains the rationale.

What did I not like about the article?  It starts out with the old saw about how the DSM 5 is sometimes known as psychiatry’s bible. I appreciate the qualifier but let’s lose the term bible in any reference to the DSM.  That descriptor is wrong at several levels – the most important one being that it is a classification system.  Please refer to it as psychiatry’s phone book or catalogue from now on, even though it is nowhere near as accurate as a phone book or any commercial catalogue.

The author goes on to describe the inclusion of prolonged grief disorder into the latest revision of DSM as controversial and then collects opinions on either side of what I consider to be an imaginary controversy. Why am I so bold to call this controversy imaginary?  Maybe it is not entirely imaginary, but it certainly is not as big a deal as it is portrayed in the article and here is why.

The first argument is that including it in the DSM means that professionals can now bill for it. In fact, all hospitals, clinics, public payers, and insurance companies require ICD-11 codes and not DSM codes.  Granted, the DSM codes are typically coordinated to match ICD-11 codes but there is not a perfect match.  ICD-11 codes are available for free and do not require a copy of the DSM 5 TR. The diagnosis of prolonged grief disorder was included in the ICD-11 in 2020 (2) and it is easier to make the diagnosis.  Quoting from reference 2:

“To meet PGDICD-11 criteria one needs to experience persistent and pervasive longing for the deceased and/or persistent and pervasive cognitive preoccupation with the deceased, combined with any of 10 additional grief reactions assumed indicative of intense emotional pain for at least six months after bereavement. Contrary to the 5th revision of the Diagnostical and Statistical Manual of Mental Disorders [DSM-5; (11)] and the 10th revision of the International Classification of Diseases [ICD-10; (12)], the ICD-11 only uses a typological approach, implying that diagnosis descriptions are simple and there is no strict requirement for the number of symptoms one needs to experience to meet the diagnostic threshold.”

The insurance company billing is further complicated by the fact that there are many other current diagnoses that can be used to treat a person severely incapacitated over a prolonged or severe course of grief.  Per my original blog Paula Clayton, MD explained this 45 years ago based on her research that also showed a small percentage of people become depressed during grief and require treatment. A prolonged grief disorder (PGD) diagnoses is not necessary and, in some cases, may lead to problems with insurance companies. It is well known that some insurance companies will not reimburse for some diagnoses that they think do not require treatment by a mental health provider. What they think of a PGD diagnosis is unknown at this time.

The second argument is that it may lead to biological treatments for the disorder. They cite a naltrexone trial for this disorder. Let me be the first to predict that the naltrexone will probably not work but I will also point out it is a medication that could be prescribed right now without putting PGD in the DSM 5 TR. The author states this may set off a competition among pharmaceutical companies for effective medications. That may be true – but what will the likely outcome be?  We already know that many people with PGD actually have treatable depression and respond to conventional treatments. We also know that those medications are all generics, very inexpensive, and the pharmaceutical benefit managers control most prescriptions for expensive drugs. These factors combined with the low prevalence of this disorder and well as the responsiveness to psychotherapy and supportive measure will not produce a windfall for Big Pharma.

There is an inherent bias by some against medical interventions for any disorder that seems to start out as a phenomenon seemingly explained by social or psychological factors. Grief was listed as one of the four major causal factors for depression in Interpersonal Psychotherapy (IPT) and there were no complaints.  IPT has been around for 40 years. Is that because the treatment emphasized was psychotherapy?  Throughout my career I have always had resources available for people who were grieving. Clergy are a professional resource but with the continued secularization of the country it is common to find that most people do not have an identifiable clergy person. Grief support groups are very common – both as self-help groups and groups run by professionals. The question is what if those resources are not enough to assist the grieving person? 

The third argument is that there will be “false positives” or people given the diagnosis when they are emerging from the symptoms. That supposes that the doctor has no discussion with the patient about what might be helpful including non-medical supportive measures and watchful waiting. It also supposes that the patient’s interest in what is happening with them specifically how it is affecting their life and whether they want to do anything about it is never discussed.  I don’t think most doctors – even if they are in a hurry operate that way.

The fourth argument is the danger of making a diagnosis and how that impacts the person. Grief is a universal phenomenon that everyone experiences many times in their life. Everyone knows that through experience. Empathically discussing with a person that this episode of grief is affecting them differently than others does not seem to be discounting or minimizing their emotions or experience to me. The very definition of empathy is that the patient agrees with the empathic statements as adequately explaining their experience.

A fifth argument buried in there is that clinician want to rapidly classify people so that they can get reimbursement. I have already addressed each half of that argument about but let me add – does naming a disorder mean that it did not exist before? There are thousands of examples in medicine and psychiatry of new diagnoses that basically classify earlier conditions where the diagnosis was never made before. A striking example from psychiatry is autoimmune encephalitis.  It was previously misdiagnosed as either a psychosis or bipolar disorder until the actual diagnosis was discovered. Rapid classification leads to many paths other than reimbursement. In the case of autoimmune encephalitis – life saving treatment.

The fundamental problem in writing articles about human biology from a political perspective is that it fails to address the biology. The biology I am referring to here are unique human conscious states and all of the associated back up mechanisms that make them more or less resilient, intelligent, and creative. Is the general classification “grief” likely to capture a large enough number of possibilities to qualify as a rigorous definition? We have known for some time that is not supported by the empirical evidence and that evidence has become more robust over the past 20 years. A small number of people experiencing grief will have a much more difficult time recovering and, in some case, will not recover without assistance. In spite of that, there remain biases against studies that focus on elucidating biological mechanisms or treatments.  It is easier to invoke emotional rhetoric like medicalization or psychiatrization and try to avoid the issue.  To the author’s credit none of those terms were used.

There is also the issue of what this new diagnosis suggests in terms of the science of psychopathology. Does this mean we are closer to classifying all of the possible problems of the human psyche and developing treatments? It reminds me of what one of my psychoanalyst supervisors used to say about the state of the art.  In those days there were basically biological psychiatrists and psychotherapists. He referred to anyone without a comprehensive formulation of the patient’s problem as a dial twister. Are we closer to becoming dial twisters?  I have some concerns about the checklist approach associated with the diagnosis and its understudied phenomenology. That is compounded by the limited time clinicians have to see patients these days and the predictable electronic health record templates with minimal typing of formulations.

Practical considerations aside only time will tell if the new research leads to better identification and treatment of people with clear complications of grief. That does not mean that science has all of the answers. It should be clear that the science of prolonged grief disorder like most of psychiatry only deals with the severe aspects of human experience.  There are clearly other ways to conceptualize grief and learn about it without science. The science is useful for mental health practitioners charged with providing treatments to the severely distressed and with grief the vast majority of people (90+%) will never see a practitioner and even fewer than that will ever see a psychiatrist.

 

George Dawson, MD, DFAPA

 

1:  Ellen Berry.  How Long Should It Take to Grieve? Psychiatry Has Come Up With an Answer. NY Times March 18,2022.

2:  Eisma MC, Rosner R, Comtesse H. ICD-11 Prolonged Grief Disorder Criteria: Turning Challenges Into Opportunities With Multiverse Analyses. Front Psychiatry. 2020;11:752. Published 2020 Aug 7. doi:10.3389/fpsyt.2020.00752

Excerpted per open-access article distributed under the terms of the Creative Commons Attribution License (CC BY).

3:  Prigerson HG, Horowitz MJ, Jacobs SC, Parkes CM, Aslan M, et al. (2013) Correction: Prolonged Grief Disorder: Psychometric Validation of Criteria Proposed for DSM-V and ICD-11. PLOS Medicine 10(12): 10.1371/annotation/a1d91e0d-981f-4674-926c-0fbd2463b5ea.

4:  Lenferink LIM, Eisma MC, Smid GE, de Keijser J, Boelen PA. Valid measurement of DSM-5 persistent complex bereavement disorder and DSM-5-TR and ICD-11 prolonged grief disorder: The Traumatic Grief Inventory-Self Report Plus (TGI-SR+). Compr Psychiatry. 2022 Jan;112:152281. doi: 10.1016/j.comppsych.2021.152281. Epub 2021 Oct 21. PMID: 34700189.

5:  Shear MK, Reynolds CF, Simon NM, Zisook S. Prolonged grief disorder in adults: Epidemiology, clinical features, assessment, and diagnosis. In Peter P Roy-Byrne and D Solomon (eds) UpToDate https://www.uptodate.com/contents/prolonged-grief-disorder-in-adults-epidemiology-clinical-features-assessment-and-diagnosis#H210445955 accessed on 03/21/2022

6:  Klerman GL, Weissman MM, Rounsaville BJ, Chevron ES.  Interpersonal Therapy of Depression.  Basic Books, New York, 1984.

7:  Ratcliffe M. Towards a phenomenology of grief: Insights from Merleau-Ponty.  European Journal of Philosophy 2019; 28: 657-669  DOI: 10.1111/ejop.12513

8:  Clayton PJ. Bereavement in Handbook of Affective of Disorders.  Eugene S. Paykel (ed). The Guilford Press. New York. 1982  pages 413-414


Supplementary 1:

Quote from an initial post on this subject 9 years ago as written by Paula Clayton, MD:

"There are many publications that deal with treating psychiatric patients who report recent and remote bereavement. It is possible to find a real or imagined loss in every patient's past. However, for the most part, because there is little evidence from reviewing normal bereavement that there is a strong correlation between bereavement and first entry into psychiatric care, those bereaved who are seen by psychiatrists should be treated for their primary symptoms. This is not to say that the death should not be discussed, but because these people represent a very small subset of all recently bereaved, they should be treated like other patients with similar symptoms but no precipitating cause. A physician seeing a recently bereaved with newly discovered hypertension might delay treatment one or two visits to confirm its continued existence, but treat it if it persists. So the psychiatrist should treat the patient with affective symptoms with somatic therapy but only if the symptoms are major and persist unduly. A careful history of past and present drug and alcohol intake is indicated. Then, the safest and most appropriate drugs to use are the antidepressants. Electroconvulsive therapy is indicated in the suicidal depressed." (Paykel p413-414)

Wednesday, January 2, 2013

A Psychiatrist Reads the Washington Post


There are an endless number of ways that the appearance of conflict of interest can be spun to make any organization look bad.  The obvious question is why that always seems to occur with psychiatry?  The arguments all follow the general form that a financial benefit resulting from work related to the pharmaceutical industry disqualifies those experts from writing objective research about medication or rendering opinions about the treatment of psychiatric disorders in general. That is the theme of the latest article from The Washington Post entitled “Antidepressants treat grief? Psychiatry panelists with ties to drug industry say yes."  It is an old story with little variation and I add some commentary based on the organization of the article.

"In what some prominent critics have called a bonanza for drug companies, the American Psychiatric Association this month voted to drop the old wording against diagnosing depression in the bereaved, opening the way for more of them to be diagnosed with major depression and thus, treated with antidepressants.”

This statement assumes that this practice is not occurring right now. In fact, it is widely known that the diagnosis of depression is not rigorously made in primary care settings. It is highly likely right now that patients suffering from grief as well as psychological adaptations to acute stress are being treated with antidepressants. There is no reason to believe that the patients being treated in primary care resemble the patients with a diagnosis of major depression in clinical trials of antidepressants.

"The change in the handbook, which could have significant financial implications for the $10 billion  US antidepressant market, was developed in large part by people affiliated with the pharmaceutical industry, an examination of financial disclosures shows.”

The previous statement talks about a "bonanza for drug companies" and builds on this image in the second statement. It ignores the fact that most commonly prescribed antidepressants are currently generics and available for as little as four dollars per month. The only two major antidepressants at this time that are not generics are Cymbalta (duloxetine) and Vibryd (vilazodone).  Where does the "10 billion dollar" figure come from?  If you read the entire article on page 5, that figure was from IMS America a company that tracks total prescriptions from American retail pharmacies.  Anyone knowing the applications for antidepressants would know that they are prescribed for many conditions other than depression including headaches, hot flashes, and chronic pain. The total retail sales figure is unlikely to reflect either drug company profits or the amount of depression being treated.

A little arithmetic is always instructive. If we assume that a physician prescribes a generic antidepressant for a patient that costs four dollars per month that translates to a total cost of $48 per year. The $10 billion/year figure quoted here would represent 208 million prescriptions or 66% of the entire population of  the U.S. taking antidepressants 12 months out of the year.  Even if we take $2 billion out of the $10 billion figure for Cymbalta and Vibryd, that results in 53% of the population taking antidepressants 12 months out of the year. Those figures are 5-8 times higher than any actual estimation of antidepressant use.  The $10 billion dollar figure is certainly eye-opening but there is plenty of evidence that it is not remotely accurate and will not have the purported impact on the pharmaceutical industry.

"About 80% of the prescriptions for antidepressants are written by primary-care physicians and others, not psychiatrists, a fact that makes the APA handbook particularly important. Faced with a patient complaining of depression-like symptoms, a general practitioner may be likely to rely on the Association's handbook for advice.”

This statement reveals the authors lack of knowledge about the practice of medicine and about the DSM that he is criticizing. The DSM is strictly a diagnostic manual and it contains no treatment recommendations. Primary care physicians are not avid readers of the DSM and that has probably led to the practice of using a DSM-based checklist – the PHQ-9.  This practice has not been promoted by the APA or the pharmaceutical industry (although the PHQ-9 is copyrighted by Pfizer pharmaceuticals).  Using a checklist to make a rapid diagnoses (in minutes) and rapidly treat large numbers of patients is promoted by managed care organizations and HMOs. That is probably the single greatest factor contributing to antidepressant prescriptions but it is ignored by the author - probably because it challenges his contention that this is all driven by conflict of interest in psychiatry rather than the business world.  It is cheaper for HMOs to treat depression with medications rather than detailed psychiatric assessments and psychotherapy.

"The Association itself runs on a budget of about 50 million a year, and for years industry funding has been critical to its operations. Today, about 14% of the Association's budget comes from pharmaceutical companies, mainly in the form of advertising at annual meetings and publications."

The author does a good job of providing no context here. Is the APA any different from other medical specialty organizations? Does advertising create a conflict of interest? Is any other print media outlet held to that standard? There is information available in those areas.   An Institute of Medicine report focused on conflict of interest showed that the APA's revenue from the pharmaceutical industry was in the middle of the pack with regard to medical specialty societies. As an example, the year that report was done the APA reported that medical companies supplied 28% of their annual income.  The American Academy of Family Physicians reported that 42% of their annual income was from pharmaceutical companies (p 220).  That same report (Recommendation 6.1) noted that increasing work for the pharmaceutical industry correlated with a 7% reduction in real physician wages and recommended that there was nothing wrong with “consulting arrangements based on written contracts for expert services to be paid for at fair market value”.   Depending on the expert involved, restricting the amount to $10,000 per year could practically mean anywhere from 2 to 10 presentations per year or about 2 1/2 weeks of contract work. 

“Other members of the committee have numerous ties to drug companies, too, and not simply conducting research, according to disclosures from last year. One was holding stock in Glaxo Smith Kline, one was a consultant to Servier and another consultant to Pfizer;  one had a grant from AstraZeneca and another a grant from Pfizer and AstraZeneca.”

This is a paragraph from a poorly written section illustrating ties between the 11 member Mood Disorders Work Group set up to draft the guidelines on major depression. There is some explanation of the selection criteria and conflict of interest criteria.  It discusses conflictof interest criteria that the APA designed and made explicit in response to this article.  It provides no context other than an off hand remark by the chairman that he probably regrets making. The article provides no reasonable context for expected reimbursement for experts as consultants to industries or the fact that this is a common practice in many academic departments on any major university campus. In some of those industries, the professional organizations actually make an effort to make sure that businesses are well represented in any process that involves making standards.

"The current handbook-the revised version will be published in the Spring-recommended against diagnosing major depression in the bereaved when the symptoms are milder and of less than two months duration. This is known as the "bereavement exclusion".  (If the signs of depression are severe-the patient has thoughts of suicide, for example-major depression is supposed to be diagnosed)….. The new handbook removes the bereavement exclusion."

There is really nothing new and nothing drastic as anticipated with removing the "bereavement exclusion". To provide a clear example I will quote a text copyrighted in 1982:

"There are many publications that deal with treating psychiatric patients who report recent and remote bereavement. It is possible to find a real or imagined loss in every patient's past. However, for the most part, because there is little evidence from reviewing normal bereavement that there is a strong correlation between bereavement and first entry into psychiatric care, those bereaved who are seen by psychiatrists should be treated for their primary symptoms. This is not to say that the death should not be discussed, but because these people represent a very small subset of all recently bereaved, they should be treated like other patients with similar symptoms but no precipitating cause. A physician seeing a recently bereaved with newly discovered hypertension might delay treatment one or two visits to confirm its continued existence, but treat it if it persists. So the psychiatrist should treat the patient with affective symptoms with somatic therapy but only if the symptoms are major and persist unduly. A careful history of past and present drug and alcohol intake is indicated. Then, the safest and most appropriate drugs to use are the antidepressants. Electroconvulsive therapy is indicated in the suicidal depressed." (Paykel p413-414).

Any psychiatrist worth his or her salt knows the difference between grief and depression and they should know the literature on treating grief, the natural history of grief, and the research on proven non-medical treatment of grief including Interpersonal Psychotherapy (IPT) and grief counseling. When you are seeing a psychiatrist, you are seeing an expert who should know the literature on grief, depression, and the differential diagnosis of depression.  Nothing in this article indicates that.  In fact, quotes are provided to suggest that the APA and psychiatry in general has an interest in redefining “the range of acceptable emotion” rather than using clinical research done by psychiatrists to limit suffering and prevent suicide.

I think the reality here indicates that there is no scandal.  The importance of the DSM-5, the appearance of conflict of interest, and the potential windfall for the pharmaceutical industry appear to be seriously overestimated.  Organized psychiatry is certainly not responsible for what happens  in primary care clinics under the direct guidance of business organizations.  There is a responsibility to establish professional standards for patients referred to psychiatrists for the assessment and treatment of complicated depressions that may occur during bereavement. The suggestion that medications may be useful in some of these situations and the importance of treating depression in bereavement has been around for at least 30 years.

George Dawson, MD, DFAPA

Peter Whoriskey.  Antidepressants to treat grief? Psychiatry panelists with ties to drug industry say yes. The Washington Post, December 26, 2012.

Clayton PJ. Bereavement in Handbook of Affective of Disorders.  Eugene S. Paykel (ed). The Guilford Press. New York. 1982  pages 413-414.

APA Reiterates Stringent Rules on Accepting Pharma Support.  Psychiatric News.  Monday December 31,2012.

Institute of Medicine (US) Committee on Conflict of Interest in Medical Research, Education, and Practice; Lo B, Field MJ, editors. Conflict of Interest in Medical Research, Education, and Practice. Washington (DC): National Academies Press (US); 2009. Available from: http://www.ncbi.nlm.nih.gov/books/NBK22942/