Tuesday, 30 April 2013

A time to grieve, a time to console, and a time to profit?

Eli Lilly and Co. are not slow to seize a business opportunity. As the American Psychiatric Association has opened up the way for the excessive diagnosing and treating of grief (through DSM-5), Eli Lilly has, it seems, a drug ready and waiting in the wings - Cymbalta.

In reality grief is not a sickness waiting for a cure; rather, it is a natural response to the loss that is an unavoidable part of life. And sadly, the older we get the more likely we are to experience the loss of family and friends.

With this in mind there are those who think that medication is an answer to the experience of grief in the elderly. In fact, the antidepressant Cymbalta (duloxetine) has been trialled as a “treatment on grief” - assuming that grief could really be treated. Dr John Shuster was the principal investigator in this drug trial of Cymbalta - sponsored by Eli Lilly. And as with most trials, it was a mere 8 weeks – not long enough to accurately assess the side-effects. In passing, it is worth mentioning that out of 44 patients referred and screened for this trial, 26 were enrolled and only 18 actually completed (3 dropped out because of the drug side-effects).  [You can read the trial specifications here.]

It seems that Eli Lilly are ahead of the game in testing Cymbalta for “bereavement-related depression” - now that DSM-5 has changed the diagnostic guidelines so that many more people are likely to be medicated for feeling down following a bereavement. As you may realise, the previous guidelines (DSM-IV) had a 2 month “bereavement exclusion” built in - to delay the experience of grief from being hastily diagnosed and medicated as depression.  But the whole notion of trying to put a time-scale on grieving seems to me quite absurd. I touch on this in my blog on grief here, “No stranger to Grief”. [...]

According to a presentation by Dr John Shuster, grief and bereavement in the elderly are “Opportunities for psychiatry”. Perhaps that’s the giveaway phrase, “opportunities for psychiatry”.  I can see that grief and bereavement are opportunities to come to terms with the loss of a loved one. I can see grief as an opportunity, when invited by the grieving person, to be alongside in their time of need.  But I don’t really see these as opportunities for psychiatry. I would go further: for me this is the language of commerce and the profit motive. It is what happens when a business opportunity is identified, what the industry calls “emerging markets” where people with needs become commodities.  

But grief is inevitably painful, can be desperate, and is not to be rushed. It is also an opportunity to attend to people at their time of need in a timely manner. I think the psychiatrist Dr Kwame McKenzie neatly sums up aspects of the process of grieving here:

“Grieving is a personal and social process that reflects both how we deal with mortality and the way we demonstrate the bonds between us. Depression is part of the grieving process, a part of letting go as well as paying one’s respects.”

Being available and yet not being intrusive is always a delicate balance to find when concerned for a person who is grieving. Respecting the natural process of grieving may well mean holding back – and holding back a felt need to medicate too. As Prof Kendler writes within this context: “As with the psychiatric response to the other major stressors to which we humans are all too frequently exposed, good clinical care involves first doing no harm, and second intervening only when both our clinical experience and good scientific evidence suggests that treatment is needed.”

Sadly, the older we get the more likely we are to experience the loss of friends and family. For some elderly people the sense of loss may prove too much and weaken their already tentative grip on life. Perhaps then grief becomes “a sickness unto death”. But as surely as spring follows winter, so death is followed by new life as one generation gives way to the next.

Mick Bramham is an Existential Psychotherapist based in Dorset, UK.
He has a particular interest in ethical issues and also how our lives are shaped by the society, circumstances and culture in which we live.
He trained at Regent's College London, and is a member of the Society for Existential analysis. 
Although he has serious concerns about the inappropriate and excessive use of mental health medications, he supports the freedom to choose (to take or not to take these drugs) and the right to be fairly informed of their limits and the risks. He offers support for people who are considering reducing or coming off psychiatric drugs.
He has a long-standing interest in non-clinical (and non-coercive) responses to mental and emotional distress.
You can read more about his work and find his contact details here. Follow Mick on Twitter @MickBramham

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