A Mental Disorder or Just Real Life for the Elderly?
Aging specialists clash over new identifications of seniors’ mental disorders in the latest edition of the bible of psychiatry, known as the D.S.M.-5.
By Kathleen Kelleher 04/05/2013
The fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, a handbook of psychiatric diagnoses, debuts next month amid a firestorm of controversy.
To the eye, the D.S.M.-5’s most obvious change is the Arabic numerals that replace Roman ones. Mental disorders are renamed, removed or redefined; there are brand new disorders designated as such, and some new disorders that are duly noted but categorized as needing further study. Though most of us will never read the D.S.M.-5, many of us will be affected by it. Considered the bible of psychiatry, the manual can determine what disorders are covered by health insurance, Medicare and Medicaid, and influence the allocation of government resources and precious research dollars. Practically speaking, the manual is used by mental health professionals and primary care physicians to diagnose and treat patients — but it may also introduce its own set of problems.
Two changes in the D.S.M.-5 could impact older people in significant ways. There is an expansion of cognitive disorders to include “mild neurocognitive disorder,” described by the APA as “changes that impact cognitive functioning.” The symptoms are described as going beyond normal signs of aging (e.g., misplacing your car keys and forgetting names). “Mild neurocognitive disorder” can be detected through objective testing and would typically be observed by the patient, or a close friend, spouse or colleague. Critics say the new categories of cognitive disorders will be misused among the vulnerable elderly population.
“Forgetfulness in old age will be a ‘minor neurocognitive disorder,’ a label encompassing an enormous new patient population (only some of whom are at real risk of dementia) and incurring huge costs of unnecessary brain imaging when there is no effective treatment,” psychiatrist Allen Frances, professor emeritus at Duke University School of Medicine, writes in Bloomberg News. Frances, who was chairman of the task force that produced the D.S.M.-IV, has been a vocal critic of all things D.S.M.-5.
But the APA contends that there is substantial clinical need to recognize people who need care for cognitive issues that go beyond normal aging. According to James Tyll, a spokesman for the APA, “Our hope is that by more accurately defining disorders, diagnosis and clinical care will be improved.” The idea is that early diagnosis of mild neurocognitive disorder will lead to early detection and treatment of cognitive decline before it progresses to major neurocognitive disorder, when it could be too late for treatment to arrest the decline. Identifying mild neurocognitive disorder early can make potential therapies like educational or brain stimulation more effective and may slow progression. And a diagnosis listed in the D.S.M.-5 is also more likely to be covered by insurance. Still, some people with mild neurocognitive disorder or mild cognitive impairment never do develop more serious dementia, but there is no way to predict who will and won’t suffer that fate.
Some geriatric specialists applaud the new disorder definition. “People with mild cognitive impairment should get treatment,” said Dr. Gary W. Small, director of the UCLA Longevity Center. “If I diagnose someone with mild cognitive impairment, if it is something more than normal aging, it helps me manage that patient better... Lots of evidence points to physical exercise, stress reduction, diet and memory techniques as a way to help compensate for memory decline,” said Small, co-author with wife GiGi Vorgan of The Alzheimer’s
Prevention Program: Keep Your Brian Healthy for the Rest of Your Life (Workman Publishing; 2012).
Other research indicates that patients given donepezil, a drug used to treat Alzheimer’s disease, slowed their rate of cognitive decline for the first year. But there was no difference after three years, Small said. Research in aging and dementia is focusing on identifying Alzheimer’s disease as early as possible, making the pre-dementia phase increasingly urgent.
An even more controversial change to the D.S.M.-5 is the revised criteria for major depressive disorder (MDD). MDD no longer includes what is called the “bereavement exclusion.” The so-called “bereavement exclusion” in the D.S.M.-IV cautioned against diagnosing someone with MDD within two months following the death of a loved one, because grief and depression symptoms appear so similar. The D.S.M.-5 removes the bereavement exclusion from MDD, listing symptoms that, when persisting for a minimum two-week period, could trigger a diagnosis of major depressive disorder. Exhibiting five or more on MDD’s list of symptoms — including feeling sad, crying, decreased appetite, insomnia, decreased interest in daily activities, fatigue, distraction and inability to function in daily life — meets the criteria for a diagnosis.
Removing the bereavement exclusion is intended to prevent major depression from being overlooked in a grieving person, according to the APA’s Tyll. But the fear among geriatricians, social workers, bereavement counselors and other mental health practitioners is that this change will lead to overdiagnosis and overmedication for something that is perfectly natural and will get better with time and support from family and friends. “I do think we have to concern ourselves with creating a medicalizing of grief and then pharmacologically treating it,” said Dr. Eric Widera, a geriatrician at the University of California San Francisco, who wrote about the issue on GeriPals.org. “You know where most mental health disorders are treated? Primary care physicians. They rely on these DSM diagnoses and criteria and prescribe most of the antidepressants. Studies have never shown that treating grief after the loss of a loved one with medication has ever improved outcomes.”
A minority of bereaved people (10 to 20 percent) experience what is called “complicated grief,” a detrimental life-disrupting variation that may call for treatment, says Widera. But people with complicated grief could still be diagnosed with MDD under the grief exclusion, Widera argues, just with a higher symptom threshold. The grief exclusion noted that a bereaved person should be diagnosed with MDD if they meet the five-symptom criteria of the disorder and demonstrate one or more of the following symptoms — an inability to function in daily life, suicidal thoughts, psychotic thinking, feelings of worthlessness or psychomotor retardation (marked slowing of thought and movement) — for more than two months. These guidelines were designed to ensure that the few people who develop truly depressive episodes after losing a loved one would not be overlooked by a clinician.
“Uncomplicated grief may cause significant distress, but for the majority of bereaved, it is an adaptive and healthy reaction to the loss of a loved one,” Widera’s blog post reads. “Most bereaved individuals will adjust to a new life without their loved one, but this takes time — certainly longer than two weeks.”
Adjusting and adapting to a new life following the death of a loved one is a painful, trying process for anyone, and it can be especially hard for older people. Rediscovering Hope, a bereavement support group, gathers weekly at the Pasadena Senior Center. Some participants are well along in the grief process, maybe even a year or two post-loss. But it is grief that unites them. They come seeking the refuge, support and solace of others’ stories of loss, sadness and survival.
“One of the things we do as clinicians that is so important is normalize the grief process,” said grief counselor Jody Casserly, L.C.S.W., who runs groups at the Pasadena Senior Center and at AIDS Project L.A. “I don’t want to be pathologizing something that is very normal — frequent crying, changes in sleep, eating and difficulty concentrating — after a major loss. The most beneficial aspect of support groups is people sharing their experiences with each other and feeling ‘I am not crazy’ or ‘I am not alone.’”
Casserly, who is also in private practice, said that the D.S.M.-5 will surely increase what insurance and Medicare covers for bereaved people diagnosed with MDD, including the benefits of individual therapy, group therapy and psychopharmacological treatment. But she warns that the older people she sees in her bereavement groups would recoil at the idea of a diagnosis of a mental illness because the members have so normalized their experiences and feelings of loss. That would not stop Casserly, who is ever-watchful for the symptoms of potential major depression in those she counsels. She does not think she needs to consult the D.S.M.-5 on the matter, but she knows that primary care physicians will. The question is, will they know how to distinguish between clinical depression, which requires treatment, and uncomplicated grief, which is the normal response to the death of a loved one?
What D.S.M.-5 critics and supporters agree on is that a great many people need a broad range of effective, pinpointed mental health support. What they cannot agree upon are the terms and language and whether a disorder deserves to be in the manual at all. It’s clear that the D.S.M.-5 will continue to be an embattled document. According to Tyll, the APA intends to use new technologies to incorporate timely, incremental updates to the manual based on “a preponderance of supportive research evidence.” That means that though many find the manual flawed, changes are ahead.