Notes & Links: August 14, 2013

We Don’t Have the Best Healthcare System in the World But We Could

The Incidental Economist makes an interesting argument until he closes with this:

“We don’t have the best health care system in the world. But we could. I long for the day when we can start talking about getting that instead of whether we should give Medicaid to people making less than the poverty line.”

I’m not sure if he saying hell with the poor and their health or let’s stop bitching about it do it, and move on to the issue at hand making what we have work better for all. Perhaps I should ask?

A Glut of Antidepressants

Roni Caryn Rabin writing in NY Times Well blog offers some insights to depression and why we have a ton o antidepressants.  (At this time is down)

Over the past two decades, the use of antidepressants has skyrocketed. One in 10 Americans now takes an antidepressant medication; among women in their 40s and 50s, the figure is one in four.

 So if you think the reason is overdiagnosed well you are right according to a study in the journal of Psychotherapy and Psychosomatics. 

“…nearly two-thirds of a sample of more than 5,000 patients who had been given a diagnosis of depression within the previous 12 months did not meet the criteria for major depressive episode as described by the psychiatrists’ bible, the Diagnostic and Statistical Manual of Mental Disorders (or D.S.M.).

So we are prescribing more antidepressants more quickly for longer periods of time. The article is rich in its analysis and thought but the best part of it are the comments which just speaks to medicine, science, research, and the Internet. Oh boy.

How Much of a Subsidy Will You Get in Obamacare? Here’s an Estimate.

Julie Appleby in the Washington Post (aka Amazon’s in house newsletter) presents work from the Kaiser Family Foundation they looked at the subsidies and stated they will average $5,548. 

Because that figure is an average, some families will get more and some will receive less when they enroll through new online marketplaces, which open Oct. 1.

Here is the link to  Kaiser Family Foundation

Grief, Depression, and Antidepressants: Really!

Back in May of 2012 the NEJM published the following article “Grief, Depression, and the DSM-5” written by Richard A Friedman, MD. I posted a look at the article and my own experiences.

“The APA for DSM-V is considering characterizing bereavement as a depressive disorder and encourage clinicians to diagnose major depression in a person with normal bereavement after two weeks of mild depressive symptoms. The data that Friedman presents shows that depressive symptoms in the context of grief are different in course and prognosis from clinical depression. Data also shows that 10% to 20% of bereaved people do not get over their loss. Friedman states that clinicians should be able to distinguish between clinical depression and uncomplicated grief, so as to ‘normalize, not medicalize, grief’.

Friedman noted that on May 9, 2012 the APA announced that bereavement exclusion will be eliminated from major depression definition but a footnote will be added indicating sadness with mild depressive symptoms should not be viewed as a major depression.

It seems the APA is having a bit of change of heart on the bereavement exclusion.  Peter Whoriskey wrote in the December 26th issue of the Washington Post “Antidepressants to treat grief? Psychiatry panelists with ties to drug industry say yes.”  Whoriskey states that the new DSM-5 removes the bereavement exclusion which will allow a person who is grieving and suffering from major depression to be treated. Though the footnote in the DSM-5 warns about confusing normal grief and mental disorder. Some critics say is too little to prevent mass marketing of antidepressants for bereaved adults. Will the average physician seeing a patient post loss of a spouse be able to identify normal depression from complicated depression? Will the strum and drang of antidepressant promotion drown out measured and deliberate diagnosis?

Whoriskey spends considerable ink on the APA panel connections to big Pharma and what that means in adding the exclusion and how this will make grief a disorder and a large lucrative target for drug development. I am not sure I disagree or agree with this analysis but I see it differently.

First, I would like to see someone or some group study palliative and hospice care and its effect on grief following the death of a loved one. Does fact palliative and hospice care treats the entire patient and the caregiver provide long-term benefits to the survivor? Will we see a lower incidence of complicated grief with families that benefited from palliation and hospice?

Second, using available support groups (, American Cancer Society, etc.) can go a long way to help those grieving at the loss of a loved one. I know for me that was an important and long-term part of my journey during my wife’s cancer treatment and passing. There are organizations out there that know and understand what we are going through and how we are coping.

Finally, we need to have more conversations care, treatment decisions, needs, and goals of care between the care team, including physicians, and the patient and family. There are 10 domains of quality care for end of life. It is my belief that if we apply these domains we can reduce complicated grieving.

1. Symptom Control

1. Communication

3. Decision Making

4. Traditions, Customs, or Way of Life

5. Religious and/or Spiritual Care

6. Psychosocial Care

7. Last Hours of Living

8. After the Death

9. Overall Patient Care

10. Overall Family Care