What’s the difference between being very shy and having social phobia? Or between a “neat freak” and a person who suffers from obsessive-compulsive disorder? Or a particularly fidgety schoolboy and a child with attention-deficit hyperactivity disorder? Distinctions between the outer bounds of “normal” and “pathological” are ubiquitous in modern life and not easy to make. People who experience loss respond in different ways, with varying degrees of intensity, and for different lengths of time. Mental health professionals find these responses difficult to predict. For example, leaders in the bereavement field have disagreed sharply and for a long time about how to define normal and abnormal grief. This professional disagreement about grief and bereavement made headlines when the American Psychiatric Association (APA) considered changing its Diagnostic and Statistical Manual of Mental Disorders (DSM). Every fifteen to twenty years, the APA revises the DSM—which establishes the criteria clinicians use to diagnose psychiatric disorders—to incorporate the latest scientific research and contemporary expert opinion. Before the most recent edition (DSM-5) came out, the APA considered two grief-related proposals that sparked very heated debate. The most controversial proposal suggested modifying how professionals diagnose major depression. The previous edition of the DSM specified that clinicians could not consider someone to have major depression if that person had lost a loved one less than two months earlier. The APA intended this “bereavement exclusion” to keep mental health professionals from mistaking grief for clinical depression. Clinical researchers Sidney Zisook, MD, at the University of California at San Diego and Katherine Shear, MD, at the Columbia University School of Social Work led one side of the debate. They argued that professionals should diagnose clinical depression even in the context of bereavement as they would following any other stressful life event such as divorce or the loss of a job. Zisook and Shear thought that people could experience both grief and depression simultaneously. Perhaps most importantly, they said, people who had clinical depression during early bereavement were no less deserving of treatment for their depression.
Creating Price Indexes for Measuring Productivity in Mental Health Care
