You’ve noticed that your partner seems sad, irritable, or overly critical. Maybe he has expressed hopelessness or guilt. You have noticed a loss of interest in his usual activities, concentration trouble, or changes in his sleep pattern. All these could be signs that your man is struggling with some form of depression.
Depression isn’t only hard for him; mood disturbances also have a big impact on your relationship. But how do you bring up the subject? Many men have difficulty talking about their feelings in the first place. The prospect of having a mental health disorder is difficult to hear for anyone. Even gentle suggestions that the problem may lie within himself will likely not be appreciated.
As the saying goes, “People don’t care what you know until they know that you care.” So what can you do to help?
Let me start by explaining what not to do.
1. Don’t say “Look on the bright side.”
People with depression may have a long list of what is wrong with the world. You as a non-depressed person may not agree and will want to convince your partner otherwise. The goal however isn’t to fix a problem on the content level or even to change his negative feelings, but to help both of you feel less isolated. So don’t talk him out of it — this doesn’t work!
Instead, aim to be fully present and willing to listen to his strong feelings. Don’t take it personally. What he says is not so much about you, but a window into his experience. Connecting during the dark times will help heal your relationship.
2. Don’t ask “Why?” and “How come?”
While it is good to show interest in his feelings and adapt a curious, non-defensive attitude, these questions are too analytical. What you’re going for is not a rational explanation, but helping him vent the feelings that will otherwise fester.
Better questions are: “Tell me why this is important to you.” “What is the most difficult part for you?” “That really bothers you, doesn’t it?” “You sound worried, what are you afraid of in this situation?” Or simply, “Tell me more!”
3. Don’t blame each other.
Even though your partner may be nagging at you, many people suffering from mood issues secretly blame themselves. He may also worry about overwhelming you with his burden or fears you may leave him if you find out how dark his thoughts are. It might help to externalize the problem. Depression can be a “third party” in the relationship and must be acknowledged as such. If the problem is neither him or you, but “it,” you can be allies in battling this together, just like you would with any other illness.
4. Don’t hesitate to encourage professional therapy.
The timing and tone is important here. “Man, you really need therapy,” is blaming or dismissive, but if you have done the work of being present and demonstrating your willingness to listen to your partner’s feelings, education on the illness can have a tremendously normalizing effect.
According to the National Institute of Mental Health, about 16% of US Americans will get Major Depressive Disorder at some point in their lives, and there are many other types of “low-grade depression” as well. Depression is very treatable with psychotherapy and/or medication, so getting a thorough medical assessment is very important.
One last piece of advice: Don’t lose sight of your own needs in the process. Sooner or later you will need attention or assistance from your partner as well, so don’t postpone your desires and requests for him indefinitely. Make sure to take good care of your own body and mind, and surround yourself with people who can be supportive to you both.
With crunch time looming for the ongoing revision of the psychiatry profession’s diagnostic manual, critics hoping to stop what they see as destructive changes are taking their campaign to the consumer media.
In early February, British psychologists and psychiatrists unhappy with proposed changes in the fifth edition of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders — the DSM-5, in its forthcoming incarnation — staged a successful press conference in London, which generated news coverage around the world.
Meanwhile, the most prominent U.S.-based critic of DSM-5, Allen Frances, MD — chairman of the task force that developed the fourth DSM edition in 1994 — has become a regular contributor to the popular Huffington Post website. Last week, he suggested there that the government should force the APA to abandon some of the proposed changes.
And the explosion in social media has allowed other, less well-connected mental health professionals and interested laypeople to create their own platforms for airing concerns about DSM-5 — starting websites and writing comments on others.
At least in part, the rising furor is driven by the DSM-5 revision schedule. The APA has committed to releasing the final version at its May 2013 meeting. Its internal process for ratifying it requires that it be in essentially final form this winter.
Thus, only a few months remain for critics to sway the DSM-5 leadership.
When Does Grief Become Depression?
Most of the criticism has focused on a few of the many dozens of changes that the DSM-5 working groups have proposed. These include eliminating the so-called bereavement exclusion in diagnosing major depression and adding new diagnoses for people with mild psychotic-like symptoms and problem child behaviors such as severe, repetitive tantrums.
The complaints have a common theme: that the DSM-5 will medicalize — and therefore stigmatize — normal human behaviors.
At the London press conference, for example, psychiatrist Nick Craddock, director of the Welsh National Centre for Mental Health in the U.K., argued that removing the bereavement exclusion would have such an effect.
Under DSM-IV criteria, someone who has lost a loved one can be diagnosed with major depression only if depression symptoms last longer than two months or if they include features not typical of normal grief, such as suicidal ideation.
The proposals for DSM-5 would drop this caveat, allowing for diagnosis of major depression two weeks after a loved one’s death.
According to the DSM-5 working group on depressive disorders, there is no evidence to justify an exclusion for grief but not for other stressors such as divorce, sudden physical disability, or losing one’s home or job.
Defenders of the proposal have also argued that individuals with normal grief may benefit from counseling, which may not be covered by insurance without a DSM-sanctioned diagnosis.
Craddock agreed, but countered that such individuals “did not need a label saying they had a mental illness.”
Similar complaints have been leveled at the proposed new diagnosis of attenuated psychosis syndrome. Its proponents intended it to cover people with persistent but mild hallucinatory symptoms and disturbed thinking — mild enough that the individuals recognize that they aren’t real, but serious enough to find the symptoms bothersome.
In a commentary published in the Feb. 18 issue of The Lancet, two researchers said it would be “premature” to include the syndrome in the DSM.
Paolo Fusar-Poli, MD, of King’s College London, and Alison R. Yung, PhD, of the University of Melbourne in Australia, said that, from the evidence so far, the population likely to receive the diagnosis “is heterogeneous in presentation, clinical needs, and outcome” — and thus too ill-defined without more research and additional diagnostic criteria.
‘Shrinking the Pool of Normality’
One British psychologist, referring to the DSM-5 as a whole, told the Guardian newspaper that its proposals “are likely to shrink the pool of normality to a puddle.”
They also allege that, by expanding the number of people potentially qualifying for a psychiatric diagnosis, DSM-5 will inevitably increase the number treated with drugs.
Another of the speakers at the London press conference, David Pilgrim, of the University of Central Lancashire in Preston, England, called it “hard to avoid the conclusion that DSM-5 will help the interests of the drug companies.”
Former New England Journal of Medicine editor Marcia Angell, MD, noted last year in the New York Review of Books that more than half of DSM-5 working group members had “significant industry interests.”
Frances, too, has written that the DSM-5 will be a “bonanza for the pharmaceutical industry.” But most of his criticisms, which he took public in 2009, have focused on the revision process.
He has been especially concerned with delays in the process — the APA had originally scheduled publication of DSM-5 for this May, but decided in 2009 to push it back one year — and what he believes has been a resulting rush to deliver a final product.
He has repeatedly called on the APA to abandon the revision in its current form. Recently he argued that the Obama administration’s decision to delay implementation of the ICD-10 classification system in the U.S. undercut the APA’s arguments for the May 2013 deadline for DSM-5.
DSM-5 Leaders Stand Their Ground
In a conversation with MedPage Today, APA President John Oldham, MD, and DSM-5 task force chairman David Kupfer, MD, defended their handling of the revision and argued that many of the criticisms were off-base.
For starters, Kupfer said, the proposed revisions were still open to change or abandonment. The DSM-5 will assume its near-final form in June or July, he said — meaning that the APA’s annual meeting in May would provide another forum to debate the changes.
“[The proposals] are still open to revision,” he said. “The door is still very much open.”
Oldham said he was satisfied with the process so far. “It’s an enormously long, and difficult, and challenging thing to do,” he said. “We’re not going to get it perfect. I don’t think anybody could. I don’t think any previous edition could.”
Oldham and Kupfer also argued in favor of removing the bereavement exclusion from the depression criteria.
Said Kupfer, “If patients are suffering not from normal sadness or grief, but are suffering from a severity of symptoms that constitute clinical depression, and need intervention, and they want help, that they should not be prevented from getting the appropriate care that they need because somebody tells them that, well, this is what everybody has when they have a loss.”
Oldham noted that extreme sadness can be triggered by any number of events — natural disasters, physical disability, job losses — yet the DSM-IV created an exclusion only for “bereavement.”
He also pointed out that there are “ranges of heritable risk for major depression” — suggesting that depression may in some sense be normal, yet deserving treatment nonetheless.
The DSM’s overarching purpose, Oldham said, is to enable “patients who need treatment [to] get it.”
Kupfer conceded that field trials of the revised criteria, by design, were not testing whether the changes would increase or decrease the number of people receiving a particular diagnosis. As a result, the critics’ worries won’t be refuted or confirmed until after the revisions go into effect.
“We won’t get 100% consensus on all the proposals,” Oldham said. “That would be totally unrealistic. But I personally think it’s been a thorough and careful process. We’re going to have disagreement. That’s going to happen.”
Research released today shows that women who have a tendency for migraines or have had them in the past, have a greater risk for developing depression.
The study gathered data on more than 36,000 women, who were all classified as not having depression. They were enrolled in the Women’s Health Study and gave information about their history of migraines.
The women also gave information about diagnoses of depression.
From 36,154, a total of 6,456 had current or past problems with migraines, and during the following 14 years of the study, more than half of them developed depression.
Those that had a history of migraines were nearly twice as likely to develop depression as those that had no history of the affliction. The results did not vary substantially, regardless of the type of migraine. Those with aura, which is described as visual disturbances that appear as flashing lights, zigzag lines or a temporary loss of vision, had the same risks as other types of migraine.
It’s useful information that patients and doctors alike should be aware of when treating depression.
A controversial decision to reclassify grief as a mental illness has been criticised by medical experts.
The change in classification was intended to add flexibility to how early people can be treated for depression following the death of a loved one. But it has led to worries that bereaved people will be treated with pills rather than empathy.
An editorial in influential medical journal, The Lancet, argues that grief does not require psychiatrists and that ‘legitimizing’ the treatment of grief with antidepressants ‘is not only dangerously simplistic, but also flawed.’
The unsigned lead editorial reads: ‘Grief is not an illness; it is more usefully thought of as part of being human and a normal response to the death of a loved one.’
The Lancet’s comments follow the American Psychiatric Association’s decision to add grief reactions to their list of mental illnesses in their fifth edition of the psychiatry ‘bible’, Diagnostic and Statistical Manual of Mental Disorders, (DSM-5), which is due out in 2013.
But The Lancet, along with many psychiatrists and psychologists have called for the changes to be halted – saying they would lead to a ‘tick box’ system that did not consider the wider needs of patients but labelled them as ‘mentally ill’.
They agree that in rare cases, bereavement will develop into prolonged grief or major depression that may merit medical treatment. However, they suggested that for the majority of the bereaved, ‘doctors would do better to offer time, compassion, remembrance and empathy, than pills.’
The DSM-5 proposal – which has been opposed by The Lancet’s editorial writers – would eliminate the so-called ‘grief exclusion.’
This ‘exclusion’ means that anyone who has experienced bereavement cannot be diagnosed as depressed for a certain period of time.
In a previous edition, DSM-III, that period of time was set at one year.
The DSM-IV reduced that period to two months and DSM-5 plans to reduce the period to just two weeks.
Although the proposed changes to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) would not directly affect clinical practice here, where doctors tend to use different international guidelines, experts say it would eventually influence research and thinking in the field.
Defending the change in timeframe, Dr. Kenneth S. Kendler, a member of the DSM-5 Mood Disorder Working Group, said it would allow for an earlier diagnosis but would by no means force it.
Simon Wessely, of the Institute of Psychiatry, King’s College, London, said ‘We need to be very careful before further broadening the boundaries of illness and disorder.’
‘Back in 1840 the Census of the United States included just one category for mental disorder.
‘By 1917 the American Psychiatric Association recognised 59, rising to 128 in 1959, 227 in 1980, and 347 in the last revision. Do we really need all these labels? Probably not. And there is a real danger that shyness will become social phobia, bookish kids labelled as Asperger’s and so on.’
Whereas people who are bereaved are currently given help where necessary, in future they might find themselves labelled as having a depressive disorder if their symptoms lasted longer than a certain period of time, he added.
Peter Kinderman, Professor of Clinical Psychology and Head of Institute of Psychology, University of Liverpool, said ‘It will exacerbate the problems that result from trying to fit a medical, diagnostic, system to problems that just don’t fit nicely into those boxes.
‘Perhaps most seriously, it will pathologise a wide range of problems which should never be thought of as mental illnesses. Many people who are shy, bereaved, eccentric, or have unconventional romantic lives will suddenly find themselves labelled as ‘mentally ill’.
Dr. Arthur Kleinman, a Harvard psychiatrist, social anthropologist and global health expert, says that the main problem is the lack of ‘conclusive scientific evidence to show what a normal length of bereavement is.’
According to the Lancet writers, ‘it is often not until 6 months, or the first anniversary of the death, that grieving can move into a less intense phase.’
They added that grieving is individual, shaped by age, gender, religious beliefs and the strength of the relationship with the lost loved one.
Five years ago, Colton and Mandersheid surveyed mortality data from eight states and concluded that, on average, Americans with major mental illness die 14 to 32 years earlier than the general population. The average life expectancy for people with major mental illness ranged from 49 to 60 years of age in the states they examined — a life span on par with many sub-Saharan African countries, including Sudan (58.6 years) and Ethiopia (52.9 years). Average life expectancy in the United States is 77.9 years. It would appear that the increase in longevity enjoyed by the general U. S. population over the past half century has been lost on those with serious mental illness (SMI). In fact, this drop in life expectancy due to mental illness would surpass the health disparities reported for most racial or ethnic groups. Yet this population is rarely identified as an underserved or at-risk group in surveys of the social determinants of health.
Why is there such a profound disparity in life expectancy for those with SMI? Disorders such as schizophrenia, major depression, and bipolar disorder are risk factors for suicide, but most people with SMI do not die by suicide. Rather, the 5 percent of Americans who have SMI die of the same things that the rest of the population experiences — cancer, heart disease, stroke, pulmonary disease, and diabetes. They are more likely to suffer chronic diseases associated with addiction (especially nicotine), obesity (sometimes associated with antipsychotic medication), and poverty (with its attendant poor nutrition and health care) and they may suffer the adverse health consequences earlier.
The risks are striking. People with a mental illness are more than twice as likely to smoke cigarettes and more than 50 percent more likely to be obese compared to the rest of the population. But this only partly explains the premature mortality. Recently, when Druss and colleagues analyzed the early mortality data derived from a nationally representative survey, they found three drivers: clinical risk factors, socioeconomic factors, and health system factors.
The clinical risk factors include the frequent co-occurrence of mental illness with heart disease, diabetes or other medical conditions, generally referred to as “comorbidity.” For example, people with major depressive disorder are at higher risk for cardiovascular disease and stroke. Conversely, for those who have had a heart attack, experiencing depression increases their risk for cardiac-related death three-fold, more than any cardiovascular variable except congestive heart failure. And people with diabetes have double the risk for depression. We do not fully understand the relationship between diabetes or heart disease and depression, but current thinking attributes the increased risk to both depressive behaviors (e.g., poor diet, low activity, low adherence to treatment) as well as some common biology such as elevated inflammatory factors.
While we are still trying to understand the cause of comorbidity between mental disorders and other health problems, the health system factors may offer a better short-term target for change. Few people in the public mental health care system are receiving high quality health care.
The Patient Protection and Affordable Care Act outlines a specific model of integrated care, the patient-centered medical home (PCMH), which could improve access and quality of health care to those with multiple chronic disorders. The PCMH model includes comprehensiveness, holistic patient-centered care, and, emphasis on care in the community. The Centers for Medicare and Medicaid Services has been tasked with piloting a series of PCMHs and studying their impact over the coming years with the goal of wider dissemination in the future. Knowing that people with SMI are a high risk group for multiple chronic disorders and targeting the PCMH for their specific needs could be an effective approach to improving health outcomes for the entire population.
Short of a new health care system, there are models for improving health outcomes for people with mental illness. Collaborative care, in which primary care and mental health providers work closely together to deliver effective treatments within the primary care setting, represents a fundamental change toward addressing mental disorders in conjunction with other physical conditions. Over the past two decades more than 40 research trials have demonstrated the effectiveness of the collaborative care model. In the case of major depression, for example, studies have shown collaborative care programs to be an effective approach for treating depression alongside other conditions, and to be more cost-effective than standard treatment. A recent study indicates that implementing this approach for depression in the Medicare system would result in cost savings of approximately $15 billion annually.
Collaborative care for depression and diabetes or depression and heart disease is the proverbial low hanging fruit. What about schizophrenia and bipolar disorder, which are usually treated in specialty mental health clinics rather than primary care? Is it better to add primary care capacity to the behavioral health center or to integrate patients with SMI into primary care? Can our current system, which separates behavioral health from health care, ever be “equal” in quality or outcomes? These remain research questions of urgent importance.
The unavoidable fact is that we will not improve overall longevity or contain health care costs in this nation without addressing the needs of the nearly 5 percent of Americans with serious mental illness. This is a population that not only dies early; they have multiple chronic diseases requiring expensive care, often in emergency rooms and intensive care units. We need better strategies for dealing with this urgent public health issue and we need to ensure that whether these strategies are collaborative care for depression or an innovative medical home for those with serious mental illness, we implement these interventions where the need is greatest.
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