Ronald W. Pies, MD

The side effect of persons with psychiatric illness like bipolar disorder going off medication can be destructive. This patient had been in trouble with the local police, who saw her as a troublemaker and a menace.

Prejudice is a net that ensnares not only those who suffer from severe psychiatric illness, but also many of us who care for individuals with bipolar and other disorders.

If claims in the non-professional media can be believed, there is a “raging epidemic of mental illness” in the US, if not world-wide-and, in one version of this narrative, psychiatric treatment itself is identified as the culprit.

Opponents in the now well-worn, “Bereavement Exclusion” debate can probably agree on one thing: of all the proposed changes in the DSM-5, the move to eliminate the bereavement exclusion has ignited the most intense emotional reaction among the general public.

In this article the topic addressed are the primary reasons for the American public’s disenchantment with psychiatry; how the profession ought to address these issues; and how we need to replace the DSM’s categorical system with one that is clinically useful for both clinicians and patients.

Much of the controversy on the relationship between grief and depression following recent bereavement has focused on whether the so-called “bereavement exclusion” in DSM-IV should be eliminated, as some have proposed, in the DSM-5.

Charles Dickens might well say of American psychiatry, “These are the best of times and the worst of times.”

The recent spate of Op-Eds in the New York Times says it all: both the psychiatric profession and the general public have strong feelings about the pending DSM-5-what many in the media like to call “Psychiatry’s Bible.” These emotions are certainly understandable.

The New York Times ran a front-page story regarding numerous controversies surrounding the DSM-5, most notably, the issue of eliminating the so-called bereavement exclusion in diagnosing a major depressive episode. Here, Dr Pies responds to Dr John Grohol, Psychologist and Editor of the Psychcentral Web site.

Some months ago, I received a stern admonition from my family doctor. My fasting blood sugar of 99 mg/dL was “right on the border”, he said, and I had better work on bringing it down. “But,” I protested, “when I was in medical school (in the 70s), the normal FBS range went up to 110 mg/dL!” "Well,” he replied a bit huffily, “they changed the criteria!”

When I was a first-year resident, a revered supervisor of mine made the statement-half-facetiously-that, “In psychiatry, you can do biology in the morning and theology in the afternoon!”

I do not hear loud applause for our current antidepressant armamentarium. I believe I hear the sound of one hand clapping.

In my view, Dr Angell’s assertions reflect both a serious misunderstanding of psychiatric diagnosis, and-equally important-a failure to address the core philosophical issues involved in her use of the terms “subjective,” “objective,” “behaviors,” and “signs.”

Dear Mrs. -- You have asked me about the cause of your mood disorder, and whether it is due to a "chemical imbalance."

The legend of the “chemical imbalance” should be consigned to the dust-bin of ill-informed and malicious caricatures.

Although the foundational and antifoundational traditions differ in their language and claims, both call into question the legitimacy of psychiatric diagnosis and treatment.

If telling patients they have “pre-clinical Alzheimer’s” or “MCI due to Alzheimer’s Disease”-absent effective treatment-produces more emotional suffering than it relieves, a difficult ethical question arises; namely, can such a disclosure be justified under the foundational principle of non-malfeasance?

I’d like to respond to Dr Cacciatore’s concerns and comments, as well as to some points raised by other readers. I also want to acknowledge the deep pain of those who have lost loved ones, and who have written in to this Web site.

The title of Gardiner Harris’s front-page story in the March 6 New York Times was blunt: “Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy.” For those of us who see our profession as a humanistic calling, this piece is likely to provoke a mixture of sadness and anger.

Is it possible to “forgive” Jared Lee Loughner for what he is alleged to have done? Is it morally justifiable to do so?

. . . her fixed state is one of intent though fruitless searching. She is inactive not because she is too lazy to work but because work has become meaningless to her; her energy is paralyzed not by sleep but by thought.”

Anyone who has written blogs or published articles online knows that the Internet is the new “Wild West,” so far as etiquette is concerned.

Have you been following the recent dust-up in the anthropology world? It all started, as Nicholas Wade wrote, “…after a decision by the American Anthropological Association at its recent annual meeting to strip the word “science” from a statement of its long-range plan.”

A meta-analysis sheds new light on the safety and efficacy of antidepressants in the acute treatment of bipolar disorder.

I do not believe that a nation as rich as ours (albeit with most wealth concentrated among the upper income levels) can shirk its moral responsibilities in the matter of providing basic health care for all its citizens.

For some patients with MDD, there are indeed “remembered gifts” that are appreciated on recovery from their depression. But this is not to say that MDD itself is “adaptive” during the course of the patient’s illness.

The recent disaster that trapped 33 Chilean miners for the past 2 months piqued my curiosity as a psychiatric researcher: how will these hearty survivors cope with the aftermath of being buried alive?

Clearly, we all share the goals of respecting-not “medicalizing”-ordinary grief; as well as recognizing and treating clinically significant depression. We differ with Dr Frances in how to achieve these goals, while remaining faithful to the best available scientific data.

My colleague Allen Frances is rightly concerned with the risk of over-calling normal grief as major depression - - that is, the risk of "false positives" - - if the DSM-IV "bereavement exclusion" is dropped in the DSM-5 while the 2-week minimum duration criterion is retained.

Psychiatric Times bids a very fond farewell to our long-time board member Jeffrey L. Cummings, MD, who was the originator of the Psychiatric Times “Brain and Behavior” column, which he penned for several years.