kind of embarrassing…

Posted on Thursday 27 December 2012

The recent article in the Washington Post deserves reading, but you probably know everything it has to say. Here’s a simple point:
Antidepressants to treat grief? Psychiatry panelists with ties to drug industry say yes
Washington Post with Bloomberg
By Peter Whoriskey
December 26, 2012

It was a simple experiment in healing the bereaved: Twenty-two patients who had recently lost a spouse were given a widely used antidepressant. The drug, marketed as Wellbutrin, improved “major depressive symptoms occurring shortly after the loss of a loved one,” the report in the Journal of Clinical Psychiatry concluded.

When, though, should the bereaved be medicated? For years, the official handbook of psychiatry, issued by the American Psychiatric Association, advised against diagnosing major depression when the distress is “better accounted for by bereavement.” Such grief, experts said, was better left to nature.

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

While no evidence has come to light showing that committee members broadened the diagnosis to aid the drug companies, the process of developing the handbook was fraught with financial links to the industry:

  • Eight of 11 members of the APA committee that spearheaded the change reported financial connections to pharmaceutical companies — either receiving speaking fees, consultant pay, research grants or holding stock, according to the disclosures filed with the association. Six of the 11 panelists reported financial ties during the time that the committee met, and two more reported financial ties in the five years leading up to the committee assignment, according to APA records.
  • A key adviser to the committee — he wrote the scientific justification for the change — was the lead author of the 2001 study on Wellbutrin, sponsored by GlaxoWellcome, showing that its antidepressant Wellbutrin could be used to treat bereavement….
They are referring to this study:
Bupropion sustained release for bereavement: results of an open trial.
by Zisook S, Shuchter SR, Pedrelli P, Sable J, and Deaciuc SC.
Journal of Clinical Psychiatry. 2001 62[4]:227-230.

OBJECTIVE: The present study was conducted to assess whether DSM-IV-defined bereavement responds to bupropion sustained release [SR].
METHOD: Twenty-two subjects who had lost their spouses within the previous 6 to 8 weeks and who met DSM-IV symptomatic/functional criteria for a major depressive episode were evaluated. Subjects completed the Hamilton Rating Scale for Depression [HAM-D], the Clinical Global Impressions scale, the Texas Revised Inventory of Grief, and the Inventory of Complicated Grief at baseline and follow-up. Subjects were treated with bupropion SR, 150 to 300 mg/day, for 8 weeks.
RESULTS: Improvement was noted in both depression and grief intensity. For the intent-to-treat group. 59% experienced a reduction of > 50% on HAM-D scores. The correlations between changes in the HAM-D scores and the grief scale scores were high, ranging from 0.61 [p = .006] to 0.44 [p = .054].
CONCLUSION: Major depressive symptoms occurring shortly after the loss of a loved one [i.e., bereavement] appear to respond to bupropion SR. Treatment of these symptoms does not intensify grief; rather, improvement in depression is associated with decreases in grief intensity. The results of this study challenge prevailing clinical wisdom that DSM-IV-defined bereavement should not be treated. Larger, placebo-controlled studies are indicated.
Their point in the article is about the ubiquitous conflicts of interest among the DSM-5 Task Force membership, and particularly in this case of a person prominent in the group recommending that the Bereavement exclusion be dropped who did an industry funded trial of a drug to treat grief. Point taken. My point is that the study itself was uncontrolled! Considering the often dramatic placebo effect in clinical trials, who has any idea what a 59% > 50% fall in HAM-D scores means?

And for that matter, is grieving with a lower HAM-D score better? My own perspective on this particular issue has to do with what they think Major Depressive Disorder really represents. Is it a Disorder, a Disease, or is it just feeling real bad? Because they seem to see it as separable from grief only by duration or magnitude. And what does grief represent? Is it simply an unwanted feeling? About the only conclusion that makes any sense is that they see it as yet another opportunity to use antidepressants. I’ve never personally heard anyone say that there was a "prevailing clinical wisdom that DSM-IV-defined bereavement should not be treated." It feels more like a straw man to get people to prescribe antidepressants to grieving people.

There are a couple of tables attached to the article that are of interest [here] showing the extent of some of these conflicts of interest. Note particularly the ones for Madhukar Trivedi who is on the APA Depression Guidelines panel [affiliated with 18 pharmaceutical manufacturers]. 

I found the whole article embarrassing on a number of counts like the extensive industry connections and the lame rationalizations that it didn’t matter. But the main embarrassment was at how trivial the whole thing seems. I don’t personally think that the question of whether or not psychiatrists give Wellbutrin or not to grieving people is much of a leading edge topic in mental health these days. Which reminded me of another recent article where I thought the same thing:
6 Things to Know About the Revised DSM-5
The Washingtonian
By Melissa Romero
December 3, 2012

On Saturday, revisions to the Diagnostic and Statistical Manual of Mental Disorders (DSM) were approved by the Arlington-based American Psychiatric Association’s board of trustees, including the elimination of the term “Asperger’s disorder” and “mental retardation.” The DSM had its last major revision almost two decades ago, in 1994. With the wealth of new scientific evidence on various mental illnesses and epidemiology, it was due time and necessary for the American Psychiatric Association to revise its current diagnostic system, APA president Dr. Dilip Jeste wrote in a statement. We spoke with APA chair Dr. David Kupfer, one of the major leaders of the task force group, to get more information about the DSM-5 revisions and what they mean for clinicians and patients.

  1. The term “Asperger’s disorder” is being dropped. A main concern among parents with children diagnosed with Asperger’s disorder was the proposal to drop the term from the manual. While it has been eliminated, it will be incorporated under the new umbrella term “autism spectrum disorder,” says Kupfer. “We decided to place autistic disorder, Asperger’s, childhood integrative disorder, and pervasive mental development disorders under one umbrella of diagnoses to allow clinicians to make more precise set of decisions and assessments about the children.”
  2. “Mental retardation” is being changed to “intellectual developmental disorder.” It’s no longer politically correct to say one suffers from “mental retardation.” The new term, intellectual developmental disorder, has long been used by the World Health Organization’s International Classification of Disorders. “We felt it was important to be aligned with what’s going on with the rest of the world,” says Kupfer. “We wanted to have this manual as harmonized with them as possible.”
  3. There’s a bigger focus on post-traumatic stress disorder (PTSD). “We paid much more attention to post-traumatic stress disorder with what’s been going on with the armed forces,” says Kupfer. That includes information on diagnoses and treatment for PTSD from sports injuries, as well.
  4. Eating disorders are more defined. “Eating disorders affect people across the whole lifespan,” says Kupfer. But the task force group felt that there were children and adolescents being diagnosed with eating disorders not otherwise specified 50 percent of the time, he adds. New guidelines include more precise diagnoses criteria. Binge-eating disorder has become a main category section, for example.
  5. The manual will be approximately 800 to 1,000 pages. The DSM-5 may be hefty, but for the first time next year, an electronic version will be available, including videos of assessments on patients, references, and more. “It’s very important to make sure patients and families really understand what’s going on,” says Kupfer. “So in many ways we’re trying to put things together that make it more user-friendly.”
  6. It may be a couple more decades until the next major revision. While it will likely be some time before we can expect a DSM-6, it may only be a few years until a DSM-5.1 or -5.2, thanks to the expected digital version of the manual. “We don’t wait to wait another 19 to 20 years to have a new revision of the whole volume,” says Kupfer. “But if there is some unexpected consequence, which we can’t anticipate, we have an opportunity to fix something two to three years from now.”
I’ve been so focused on the quirky things they were trying to add and the botched Field Trials that I failed to notice how inconsequential the changes they did make actually were. A few name changes and changes in emphasis. Let’s face it, there’s not really very much there. After such a lofty lead-in, there’s little to show for the last twenty years. That’s kind of embarrassing too…

Pharmalot‘s take on the WaPo article: Bereavement, Depression & Happy Drugmakers
    December 27, 2012 | 8:14 PM

    So when will the APA become irrelevant? Only after 90% of active members finally drop the membership, or just drop dead? Doubt I will need meds for that bereavement then. Yes, this is an incredibly harsh comment. Thanks to the pending double whammy of CPT code changes and then DSM 5 later this year.

    Again, who in their right mind belongs to this organization!?

    December 27, 2012 | 9:40 PM

    I just hope most psychiatrists are sensible people and don’t make snap judgments about patients using idiosyncratic interpretations of words in the DSM. I think psychiatrists need to become more user-friendly themselves! If they would just mix with ordinary people, understand their daily lives, economic situations and a little about how benefit eligibility is decided, people could live less disrupted lives when mental health issues appeared. As for anti-depressants for bereavement- surely primary care physicians are in a better position to decide whether a person is grieving “normally” or if they are having extended and “out of control” grief. I can remember my father grieving most abnormally after my mother died (she was 81, he 93 at the time) and he was crying all the time, unable to feed himself properly even with delivered meals, the house was a filthy mess and he would put his head on the doctors’ desk and say- “help me get free of the pain”. They would say “You have to pull yourself together Mr W. Age is always accompanied by pain.” and ushered him out the door. As a psychologist, I couldn’t do anything with him. He needed some pills and appropriate care. This sort of distinction in levels of grieving needs to be communicated more widely- how about it doc?

    December 27, 2012 | 10:09 PM


    I couldn’t agree more. If a person is ill like your father, you do whatever it takes to help. My complaint about the DSM-5 decision is that it’s not designed for the situation you describe, it’s a general statement aimed at using more drugs – not based on the individual patient, but based on a code book put together by industry-influenced KOLs. The DSM-5 is not a book on therapeutics, it’s supposed to be about diagnosis.

    December 28, 2012 | 12:51 PM

    Non-psychiatrists are going to take a cue from this kind of drug advocacy without looking too deeply at the conflict of interest issues and be handing out Wellbutrin etc. reflexively whenever a patient expresses grief.

    The psychiatrist I see, who is head and shoulders above any of the DSM-5 clowns, says grieving is our way of letting go so we can start again. (He hasn’t prescribed SSRIs in 10 years; he recognized that they were too strong.)

    Many people going through antidepressant withdrawal syndrome, often after having been on antidepressants for years, say that as their nervous systems return to normal, they pick up grieving (or processing painful experiences) right where they left off. The drugs only stymie important emotional reorganization processes.

    These suggests the “efficacy” of antidepressants is that they are emotional anesthetics interfering with learning and maturing. Some people interpret the effect as beneficial. But certainly in the case of grief, they are not appropriate.

    December 30, 2012 | 7:31 PM

    I agree with the main thrust of 1boringoldman’s post– the big news about DSM-5 is that so little progress has been made in Psychiatry over the past 25 years despite the KOL’s protests of breathtaking advances in neuroscience, blah, blah, blah. The news media may focus on Asperger’s (it’s gone!) and the nonsense about bereavement. But what’s big news is: a) the lack of significant advances and perhaps most notably, the apparent REDUCTION in the reliability of psychiatric diagnosis, relative to DSM-IV, as assessed by the DSM-5 field trials. Folks, we are regressing and not progressing! So why don’t we just turn back time and revert to DSM-II? Hell, it was a better classification scheme, especially regarding major depression, even with its psychodynamic flavor. And it was also a lot shorter and easier to read!

    December 31, 2012 | 11:46 AM

    I couldn’t agree more with the general points here, especially about DSM-V. I’d just add that anyone who starts handing out meds for grief is by definition going to medicate a lot of seniors. And Wellbutrin has a stellar record of raising people’s blood pressure and causing rapid or irregular heartbeats. Maybe this is, um, not such a great idea? I bet you dollars to donuts the subjects in this study were screened to exclude anyone with hypertension or heart disease, and that the average age was under 60.

    (This happened to me on Wellbutrin as a middle-aged female with no previous hypertension. My GP knew what was going on; any monkey who knew how to use Google knew what was going on. My psychiatrist did not. He advised that “antidepressants” generally did not raise blood pressure but if mine was going up I should consult my GP for “treatment.” Oy.)

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