{"id":21809,"date":"2012-04-06T00:22:01","date_gmt":"2012-04-06T04:22:01","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=21809"},"modified":"2012-04-06T04:34:09","modified_gmt":"2012-04-06T08:34:09","slug":"nothing-good","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2012\/04\/06\/nothing-good\/","title":{"rendered":"nothing good…"},"content":{"rendered":"\n

I’ve been thinking about why the DSM-5 deliberations about the Bereavement Exclusion sticks in my craw. It really shouldn’t matter, since it doesn’t matter when I see a patient. I don’t really add up symptoms to see if they support a DSM-IV diagnosis of Major Depressive Disorder to decide about what to do. So why do I even care what some group of non-clinicians are thinking about the allowable time limit for symptomatic grieving? When does it cross over into the area of Mental Illness proper? In truth, it seems a foolish mind game – like whatever mental masterbation means. I had a thought today that clarifies for me some of why it bothers me so much. It’s not about the afflicted person, or really even about diagnosis, it’s about legitimacy<\/font><\/strong>. In fact, much of the blah, blah, blah in psychiatry over the last three decades is about legitimacy. What is a legitimate mental illness<\/font><\/strong>? In medicine proper, that question is usually resolved by diagnosis, confirmed by objective measures, and treated accordingly. In psychiatry, it’s not so clear.<\/p>\n

The DSM-III revision was heavily influenced by the question of legitimacy. Insurers were up in arms about paying for long psychotherapies, psychoanalysis, in-patient hospitalizations, and there was a fear that coverage for mental illness would essentially disappear. That was not the only force for the radical change in the diagnostic scheme, but it was important. Psychiatric  diagnoses were made much more objective, "medical-like," and the insurers began to create DRGs [diagnosis-related groups] and other criteria to limit payment for a given diagnosis. Funding for inpatient treatment and outpatient psychotherapy was drastically limited resulting in the closing of hospitals and dramatic changes in treatment delivery – limitations tightened more severely with the coming of Managed Care in the early 1990s. So the DSM-III, a diagnostic system intended for coding illness became a reimbursement system, legitimizing mental illnesses for third party payment – a listing of legitimate mental illnesses<\/font><\/strong>.<\/p>\n

That’s what bothers me about the obsessive ruminations about the  Bereavement Exclusion. Of course if you see a patient who is having a difficult time with their grief and they need either emotional support, or exploratory psychotherapy, or maybe you think medications might be helpful, you’d do what seemed warranted. The idea that it had to be turned into a mental illness [as in Major Depressive Disorder] to legitimize treatment for whatever reason seems strange to me. The thing that legitimizes it is the amount of pain or dysfunction, not the name on a piece of paper. And, by the way, Major Depressive Disorder doesn’t actually exist. It’s a construct that is by any report a hopelessly heterogeneous collage of conditions constructed originally to destroy the idea of Depressive Neurosis, and maintained to give the pharmaceutical industry the widest audience for their antidepressant potions. Major Depressive Disorder [MDD] is itself "illegitimate." But I digress, the whole idea of categorizing people to legitimize<\/font><\/strong> their being treated and legitimize<\/font><\/strong> the insurers directing treatment based on the category is really irrational medicine. It’s justified to keep patients and doctors from cheating the insurers, I guess. But it’s demeaning to patients and physicians, generic to a fault, promotes lying to do the right thing, and hardly means that patients will get proper treatment. The priorities are upside down. <\/p>\n

Dr. Kendler’s discussion of this issue as a spokesperson for the DSM-5 Task Force [depressing ergo-mania…<\/font><\/strong><\/u><\/a>] is more rationalization than rationale. He accepts the unity of Major Depressive Disorder and argues that if grief symptoms meet MDD criteria, grief has become MDD. That kind of diagnosis reification haunts the DSM-5 effort. To me, the fact that Insurers like the fact that most medical diseases have objective markers and don’t like our not having them is not really our problem. Tailoring a diagnostic system to fit their needs to legitimize illness just isn’t sensible – and complicates and confuses an already difficult task.<\/p>\n

Maximizing the market for pharmaceutical manufacturers, legitimizing illness for third party carriers, creating disease labels to justify treatment, adjusting treatment based of the various health-care industry’s needs or the factional ideologies du jour, ignoring the diagnostic needs of the majority of mental health professionals [not psychiatrists] – what in the hell are we thinking? <\/p>\n

Nothing good, I think…<\/div>\n
\n
and speaking of illegitimate, there’s this<\/font><\/strong><\/u><\/a> obvious point which I should’ve included…<\/div>\n","protected":false},"excerpt":{"rendered":"

I’ve been thinking about why the DSM-5 deliberations about the Bereavement Exclusion sticks in my craw. It really shouldn’t matter, since it doesn’t matter when I see a patient. I don’t really add up symptoms to see if they support a DSM-IV diagnosis of Major Depressive Disorder to decide about what to do. So why […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-21809","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/21809","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=21809"}],"version-history":[{"count":6,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/21809\/revisions"}],"predecessor-version":[{"id":43839,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/21809\/revisions\/43839"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=21809"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=21809"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=21809"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}