“I don’t think these connections create any bias at all,” Fawcett said. “People can say we were biased. But it assumes we have no intelligence of our own.
“There has to be some cooperation between academia and pharma if you want to make any progress. People need to realize that.”
What is ‘normal’ grief?
One of the reasons that the selection of panel members on such groups is so important is that the choices they make are difficult and the evidence sometimes sparse or ambiguous. Their beliefs on basic philosophical questions matter.
In this case, what is the “normal” course of mourning?
Generally, when a person has five of nine depressive symptoms — fatigue, insomnia, sadness, or others — for two weeks or more, the DSM called for a diagnosis of major depression.
The dispute arose over what to do about diagnosing depression in patients who are recently bereaved.
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. The proponents of the revision say this allows for a person who is grieving and suffering from major depression to be treated.
“We thought the evidence was overwhelming that if depression occurs in someone who is bereaved that it should be taken as seriously as any other major depression,” Zisook said. “We are doing that person a disservice if we say they’re not really depressed.”
Fawcett, the chairman of the group, and Zisook, a key group adviser, have specialized in suicide and say they see a danger in withholding diagnosis. Zisook is co-directing a suicide prevention program at the University of California San Diego.
“The consequences of missing a major depression can be profound,” he said.
A note in the new handbook is supposed to warn physicians against confusing normal grief and a mental disorder, but some prominent critics say that’s far too little to prevent drug companies from pushing pills on the bereaved.
Allen Frances, an emeritus professor from Duke University who headed the previous revision of the DSM, has called the change a “bonanza” for drug companies.
The new book “legalizes the marketing of grief as depression,” he said. “They’re acting as if the footnote will change the world — but only academics would think the footnote would matter.”
Guided by the new handbook, a primary-care doctor, “who sees their average patient for seven minutes,” will be far more likely to diagnose depression in people who are suffering normal grief, Frances said, particularly under pressure from drug salespeople.
In putting together the previous DSM book, Frances said he learned that if a diagnosis “can be made into a fad, it will be made into a fad. If something can be twisted because a buck can be made from it, it will be twisted.”
Mario Maj, one of the panel members who has declared no financial ties to the industry, declined to be interviewed for this article, saying the panel’s deliberations were supposed to be confidential.
But in a February editorial in the journal World Psychiatry, he appeared to embrace the logic of the old diagnostic manual.
“A major depressive syndrome is indeed an ‘expectable response’ to the death of a loved one,” he wrote.
Some prominent critics of the new DSM also say much of the fear of suicides in the bereaved is unsupported.
Jerome C. Wakefield, professor at New York University who has studied the distinctions between “normal” grief and mental disorders, said that in a major national survey, none of the bereaved who now could be subject to a diagnosis of depression had attempted suicide. Other data sets, he said, showed similar results — indeed, such individuals are less likely to attempt suicide than someone in the general population.
The APA’s new stance on bereavement is “narrowing the range of acceptable emotion,” Wakefield said. While he doesn’t think the experts on the committee acted out of “explicit venality or self interest,” he added: “Once you classify these forms of grief as disorders, the symptoms become a target for drug development.”