LETTERS
Letters to the Editor Grief, Bereavement and Depression: A Clarification TO THE EDITOR: In his Personal Accounts column in the
February issue (1), Mark Ragins says many good and wise things about both the benefits and the limitations of medication, which I have sometimes likened to fire: it can heat your house or burn it down, depending on whether it is used judiciously and for the right reasons. But with respect to the DSM-5 and grief, I would like to offer a clarification. Dr. Ragins writes, “I’m particularly disturbed that in DSM-5 we’ve eliminated grief and folded it into major depression. Grief is important suffering. It’s how we know we loved. It’s how we honor our loss. It’s how we rebuild our hearts to love again. It’s not just a depressive symptom to be eliminated so we feel better.” In fact, DSM-5 does not eliminate grief or “fold it into major depression.” By eliminating the so-called bereavement exclusion, DSM-5 simply allows a diagnosis of major depressive disorder to be made in the context of a recent death of a loved one—but only if the full criteria for symptoms, duration, severity, and impairment for major depressive disorder are met. The extensive footnote on page 161 of the DSM-5 gives some important clinical guidelines that help distinguish the normal and adaptive grief response from major depressive disorder. As Dr. Ragins notes, grief is not a “depressive symptom” but a part of life, love, and loss. Yet grief does not immunize a patient to major depression (2). REFERENCES 1. Ragins M: Do I enjoy prescribing medications? Psychiatric Services 66:118–120, 2015 2. Pies RW, Zisook S, Shear MK: Distinguishing grief, complicated grief, and depression. Medscape Psychiatry, Dec 26, 2014. Available at www.medscape.com/viewarticle/836977 Ronald Pies, M.D. Dr. Pies is with the Department of Psychiatry, Tufts University School of Medicine, Boston, and with the Department of Psychiatry, SUNY Upstate Medical University, Syracuse, New York. Psychiatric Services 2015; 66:442; doi: 10.1176/appi.ps.660404
Grief, Bereavement and Depression: A Clarification: In Reply IN REPLY: I appreciate Dr. Pies’ comments. However, I’m not
arguing that it is impossible to have major depression and to be grieving. I’m arguing that it is likely that someone experiencing serious grief will meet the major depression criteria and, despite the DSM-5 cautionary note and footnote, be diagnosed as having major depression—even though the 442
ps.psychiatryonline.org
individual does not actually have any disorder, illness, or disease. Why? Because giving individuals a diagnosis of major depression makes them legitimate psychiatric patients, authorizes treatment, gets them a prescription, gets us paid, and gets them sick leave and maybe even disability payments. All of which may distract them from the support in grieving that would actually help them. I recently saw a documentary about five people with bipolar disorder, only one of whom I thought had the disorder, even though all of them more or less met the criteria. The other four were an emotionally damaged rape victim, an ex–foster care kid who became a lonely speed-addict artist, a woman with an erratic life and a borderline personality, and her boyfriend who she was “driving crazy.” All four of those people could have received helpful services, but they had been diverted into a bipolar diagnosis, pill compliance and noncompliance, and a mental illness identity—all of which likely won’t be of much help. Also, the funding that could go into other, more helpful services is diverted into these medical services. Maybe all DSM-5 diagnoses should have a list of human experiences that could result in meeting the criteria for the diagnosis, along with a note that reminds DSM-5 users that such persons do not necessarily have the disorder and that asks the clinician to consider how the person could be helped without becoming a psychiatric patient. For example, a clinician might say, “You might not have major depression, even though you meet these criteria, because you’re heavily bereaved. But you can be supported in your grief.” Mark Ragins, M.D. Psychiatric Services 2015; 66:442; doi: 10.1176/appi.ps.660405
Smoking and Smoking Cessation Treatment Among Hospitalized Psychiatric Patients TO THE EDITOR: Cigarette smoking is the leading preventable
cause of mortality in the United States, and most psychiatric hospitals are now smoke free (1). The American Psychiatric Association (APA) recommends use of nicotine replacement therapy (NRT) to manage nicotine withdrawal in the hospital (2), but there are few reports about how this recommendation has been implemented. We report on the smoking status and smoking cessation treatment received by all patients (N5392) admitted during April 2014 to the general adult inpatient units of a 330-bed, not-for-profit psychiatric hospital in Maryland. Data were collected from electronic medical records. The study was approved by the hospital’s institutional review board. Psychiatric Services 66:4, April 2015
LETTERS
At admission, 194 patients (49%) reported that they were smokers. Smokers were more likely to be male (x257.96, df51, p5.005), to be older (F55.12, df51 and 391, p5.02), to have a diagnosis of a co-occurring substance use disorder (x2585.7, df51, p,.001), to have less education (F513.3, df51 and 391, p,.001), and to be unemployed (x259.3, df52, p5.009). A regression analysis indicated that patients with a co-occurring substance use diagnosis (excluding nicotine or caffeine) were 7.6 times (95% confidence interval54.6–12.6) more likely than patients without this diagnosis to be smokers. Of the 194 smokers, 76% (N5148) indicated that they were interested in quitting, and of these, 72% (N5107) said that they would like to pursue quitting after hospital discharge. Proportionately more females than males were interested in quitting (x257.0, df51, p5.008). Among smokers, 38 (20%) were given a diagnosis of nicotine dependence. A total of 183 smokers (94%) were prescribed NRT, and 164 (85%) used NRT during their stay. NRT options were the inhaler, patch, and gum, and 45 smokers (23%) were prescribed more than one type. The most commonly prescribed form was the inhaler, prescribed to 166 and used by 143 smokers, followed by the patch, prescribed to 48 smokers, and then gum. On discharge, 28 smokers (14%) were provided with a formal smoking cessation recommendation, the most common of which was a bupropion prescription (N513 of 28, 46%). The second most common was referral to the Maryland Quitline (N512 of 28, 43%). In conclusion, we found that almost half of all hospitalized patients reported being smokers, a prevalence much higher than in the local general population (3). In contrast to previous studies (4), our study did not find that individuals with schizophrenia were disproportionately represented among smokers. The co-occurrence of a substance use disorder was the strongest predictor of smoking. Even though a minority of smokers had a diagnosis of nicotine dependence, the vast majority used NRT during the inpatient stay, consistent with APA recommendations, and a higher proportion than in a recent study (5). Provision of smoking cessation guidance at discharge was limited, suggesting that treatment of nicotine dependence was not seen as a priority. However, a large proportion of patients expressed an interest in quitting, and their admission to a smoke-free hospital provided an opportunity to introduce smoking cessation treatment. More hospitals should use this opportunity to help patients quit smoking. REFERENCES 1. CDC: Smoking and Tobacco Use. Atlanta, Ga, Centers for Disease Control and Prevention, 2014. Available at www.cdc.gov/tobacco/ data_statistics/fact_sheets/fast_facts 2. Practice guideline for the treatment of patients with substance use disorders, 2nd ed; in American Psychiatric Practice Guidelines for the Treatment of Psychiatric Disorders: Compendium 2006. Arlington, Va, American Psychiatric Association, 2006 3. Dickerson F, Stallings CR, Origoni AE, et al: Cigarette smoking among persons with schizophrenia or bipolar disorder in routine clinical settings, 1999–2011. Psychiatric Services 64:44–50, 2013 Psychiatric Services 66:4, April 2015
4. Diaz FJ, James D, Botts S, et al: Tobacco smoking behaviors in bipolar disorder: a comparison of the general population, schizophrenia, and major depression. Bipolar Disorders 11:154–165, 2009 5. Leyro TM, Hall SM, Hickman N, et al: Clinical management of tobacco dependence in inpatient psychiatry: provider practices and patient utilization. Psychiatric Services 64:1161–1165, 2013 Rachel Walsh Lucy Schweinfurth Faith Dickerson, Ph.D., M.P.H. Ms. Walsh is an undergraduate student at Carnegie Mellon University, Pittsburgh, Pennsylvania. Ms. Schweinfurth and Dr. Dickerson are with the Stanley Research Program, Sheppard Pratt Hospital, Baltimore. The authors report no financial relationships with commercial interests. Received September 29, 2014; revision received October 22, 2014; accepted December 4, 2014. Psychiatric Services 2015; 66:442–443; doi: 10.1176/appi.ps.201400446
Symptom Severity and Readiness to Quit Among Hospitalized Smokers With Mental Illness TO THE EDITOR: Beliefs prevail that mental illness and greater
symptom severity are major barriers to interest in and success with quitting smoking (1). Yet recent studies have found that 80%289% of smokers hospitalized for psychiatric treatment intend to quit smoking within the next six months (2,3). Smoking contributes to and exacerbates numerous general medical conditions, and persons with mental illness report poorer health than the general population (4). Little is known regarding the role of health and intentions to quit smoking among individuals with acute mental illness. In a sample of 956 adult daily smokers recruited during a smoke-free psychiatric hospitalization (2009–2013), we examined the association of psychiatric and general medical symptom severity with tobacco dependence and readiness to quit. The study was approved by an institutional review board and conducted at three San Francisco Bay Area hospitals. Participants provided informed consent. The following measures were completed during hospitalization by interview: mental and physical functioning (SF-12); psychiatric symptom severity (BASIS-24); and cigarette dependence (Fagerström Test for Cigarette Dependence [FTCD]). Confidence, desire, and perceived difficulty with quitting and smoking stage of change were also assessed. With a 73% recruitment rate, the sample was representative of patients at participating hospitals: male, 51%; non-Hispanic Caucasian, 48%; African American, 23%; other race-ethnicity, 29%; and employed, 21%. Most (66%) had co-occurring disorders: substance use disorder, 61%; bipolar disorder, 32%; nonaffective psychosis, 27%; PTSD, 39%; unipolar depression, 27%; and ADHD, 28%. Before hospitalization, participants averaged 17610 cigarettes per day and had smoked for 19614 years, with moderate dependence (FTCD score, 562 out of possible 10); 30% did not intend to quit in the near future (precontemplation), 47% intended to quit in six months (contemplation), and 24% were preparing to quit in the next month. In multivariate regression models adjusting for age, sex, race-ethnicity, income, education, hospital site (academic ps.psychiatryonline.org
443
Letters to the Editor Grief, Bereavement and Depression: A Clarification TO THE EDITOR: In his Personal Accounts column in the
February issue (1), Mark Ragins says many good and wise things about both the benefits and the limitations of medication, which I have sometimes likened to fire: it can heat your house or burn it down, depending on whether it is used judiciously and for the right reasons. But with respect to the DSM-5 and grief, I would like to offer a clarification. Dr. Ragins writes, “I’m particularly disturbed that in DSM-5 we’ve eliminated grief and folded it into major depression. Grief is important suffering. It’s how we know we loved. It’s how we honor our loss. It’s how we rebuild our hearts to love again. It’s not just a depressive symptom to be eliminated so we feel better.” In fact, DSM-5 does not eliminate grief or “fold it into major depression.” By eliminating the so-called bereavement exclusion, DSM-5 simply allows a diagnosis of major depressive disorder to be made in the context of a recent death of a loved one—but only if the full criteria for symptoms, duration, severity, and impairment for major depressive disorder are met. The extensive footnote on page 161 of the DSM-5 gives some important clinical guidelines that help distinguish the normal and adaptive grief response from major depressive disorder. As Dr. Ragins notes, grief is not a “depressive symptom” but a part of life, love, and loss. Yet grief does not immunize a patient to major depression (2). REFERENCES 1. Ragins M: Do I enjoy prescribing medications? Psychiatric Services 66:118–120, 2015 2. Pies RW, Zisook S, Shear MK: Distinguishing grief, complicated grief, and depression. Medscape Psychiatry, Dec 26, 2014. Available at www.medscape.com/viewarticle/836977 Ronald Pies, M.D. Dr. Pies is with the Department of Psychiatry, Tufts University School of Medicine, Boston, and with the Department of Psychiatry, SUNY Upstate Medical University, Syracuse, New York. Psychiatric Services 2015; 66:442; doi: 10.1176/appi.ps.660404
Grief, Bereavement and Depression: A Clarification: In Reply IN REPLY: I appreciate Dr. Pies’ comments. However, I’m not
arguing that it is impossible to have major depression and to be grieving. I’m arguing that it is likely that someone experiencing serious grief will meet the major depression criteria and, despite the DSM-5 cautionary note and footnote, be diagnosed as having major depression—even though the 442
ps.psychiatryonline.org
individual does not actually have any disorder, illness, or disease. Why? Because giving individuals a diagnosis of major depression makes them legitimate psychiatric patients, authorizes treatment, gets them a prescription, gets us paid, and gets them sick leave and maybe even disability payments. All of which may distract them from the support in grieving that would actually help them. I recently saw a documentary about five people with bipolar disorder, only one of whom I thought had the disorder, even though all of them more or less met the criteria. The other four were an emotionally damaged rape victim, an ex–foster care kid who became a lonely speed-addict artist, a woman with an erratic life and a borderline personality, and her boyfriend who she was “driving crazy.” All four of those people could have received helpful services, but they had been diverted into a bipolar diagnosis, pill compliance and noncompliance, and a mental illness identity—all of which likely won’t be of much help. Also, the funding that could go into other, more helpful services is diverted into these medical services. Maybe all DSM-5 diagnoses should have a list of human experiences that could result in meeting the criteria for the diagnosis, along with a note that reminds DSM-5 users that such persons do not necessarily have the disorder and that asks the clinician to consider how the person could be helped without becoming a psychiatric patient. For example, a clinician might say, “You might not have major depression, even though you meet these criteria, because you’re heavily bereaved. But you can be supported in your grief.” Mark Ragins, M.D. Psychiatric Services 2015; 66:442; doi: 10.1176/appi.ps.660405
Smoking and Smoking Cessation Treatment Among Hospitalized Psychiatric Patients TO THE EDITOR: Cigarette smoking is the leading preventable
cause of mortality in the United States, and most psychiatric hospitals are now smoke free (1). The American Psychiatric Association (APA) recommends use of nicotine replacement therapy (NRT) to manage nicotine withdrawal in the hospital (2), but there are few reports about how this recommendation has been implemented. We report on the smoking status and smoking cessation treatment received by all patients (N5392) admitted during April 2014 to the general adult inpatient units of a 330-bed, not-for-profit psychiatric hospital in Maryland. Data were collected from electronic medical records. The study was approved by the hospital’s institutional review board. Psychiatric Services 66:4, April 2015
LETTERS
At admission, 194 patients (49%) reported that they were smokers. Smokers were more likely to be male (x257.96, df51, p5.005), to be older (F55.12, df51 and 391, p5.02), to have a diagnosis of a co-occurring substance use disorder (x2585.7, df51, p,.001), to have less education (F513.3, df51 and 391, p,.001), and to be unemployed (x259.3, df52, p5.009). A regression analysis indicated that patients with a co-occurring substance use diagnosis (excluding nicotine or caffeine) were 7.6 times (95% confidence interval54.6–12.6) more likely than patients without this diagnosis to be smokers. Of the 194 smokers, 76% (N5148) indicated that they were interested in quitting, and of these, 72% (N5107) said that they would like to pursue quitting after hospital discharge. Proportionately more females than males were interested in quitting (x257.0, df51, p5.008). Among smokers, 38 (20%) were given a diagnosis of nicotine dependence. A total of 183 smokers (94%) were prescribed NRT, and 164 (85%) used NRT during their stay. NRT options were the inhaler, patch, and gum, and 45 smokers (23%) were prescribed more than one type. The most commonly prescribed form was the inhaler, prescribed to 166 and used by 143 smokers, followed by the patch, prescribed to 48 smokers, and then gum. On discharge, 28 smokers (14%) were provided with a formal smoking cessation recommendation, the most common of which was a bupropion prescription (N513 of 28, 46%). The second most common was referral to the Maryland Quitline (N512 of 28, 43%). In conclusion, we found that almost half of all hospitalized patients reported being smokers, a prevalence much higher than in the local general population (3). In contrast to previous studies (4), our study did not find that individuals with schizophrenia were disproportionately represented among smokers. The co-occurrence of a substance use disorder was the strongest predictor of smoking. Even though a minority of smokers had a diagnosis of nicotine dependence, the vast majority used NRT during the inpatient stay, consistent with APA recommendations, and a higher proportion than in a recent study (5). Provision of smoking cessation guidance at discharge was limited, suggesting that treatment of nicotine dependence was not seen as a priority. However, a large proportion of patients expressed an interest in quitting, and their admission to a smoke-free hospital provided an opportunity to introduce smoking cessation treatment. More hospitals should use this opportunity to help patients quit smoking. REFERENCES 1. CDC: Smoking and Tobacco Use. Atlanta, Ga, Centers for Disease Control and Prevention, 2014. Available at www.cdc.gov/tobacco/ data_statistics/fact_sheets/fast_facts 2. Practice guideline for the treatment of patients with substance use disorders, 2nd ed; in American Psychiatric Practice Guidelines for the Treatment of Psychiatric Disorders: Compendium 2006. Arlington, Va, American Psychiatric Association, 2006 3. Dickerson F, Stallings CR, Origoni AE, et al: Cigarette smoking among persons with schizophrenia or bipolar disorder in routine clinical settings, 1999–2011. Psychiatric Services 64:44–50, 2013 Psychiatric Services 66:4, April 2015
4. Diaz FJ, James D, Botts S, et al: Tobacco smoking behaviors in bipolar disorder: a comparison of the general population, schizophrenia, and major depression. Bipolar Disorders 11:154–165, 2009 5. Leyro TM, Hall SM, Hickman N, et al: Clinical management of tobacco dependence in inpatient psychiatry: provider practices and patient utilization. Psychiatric Services 64:1161–1165, 2013 Rachel Walsh Lucy Schweinfurth Faith Dickerson, Ph.D., M.P.H. Ms. Walsh is an undergraduate student at Carnegie Mellon University, Pittsburgh, Pennsylvania. Ms. Schweinfurth and Dr. Dickerson are with the Stanley Research Program, Sheppard Pratt Hospital, Baltimore. The authors report no financial relationships with commercial interests. Received September 29, 2014; revision received October 22, 2014; accepted December 4, 2014. Psychiatric Services 2015; 66:442–443; doi: 10.1176/appi.ps.201400446
Symptom Severity and Readiness to Quit Among Hospitalized Smokers With Mental Illness TO THE EDITOR: Beliefs prevail that mental illness and greater
symptom severity are major barriers to interest in and success with quitting smoking (1). Yet recent studies have found that 80%289% of smokers hospitalized for psychiatric treatment intend to quit smoking within the next six months (2,3). Smoking contributes to and exacerbates numerous general medical conditions, and persons with mental illness report poorer health than the general population (4). Little is known regarding the role of health and intentions to quit smoking among individuals with acute mental illness. In a sample of 956 adult daily smokers recruited during a smoke-free psychiatric hospitalization (2009–2013), we examined the association of psychiatric and general medical symptom severity with tobacco dependence and readiness to quit. The study was approved by an institutional review board and conducted at three San Francisco Bay Area hospitals. Participants provided informed consent. The following measures were completed during hospitalization by interview: mental and physical functioning (SF-12); psychiatric symptom severity (BASIS-24); and cigarette dependence (Fagerström Test for Cigarette Dependence [FTCD]). Confidence, desire, and perceived difficulty with quitting and smoking stage of change were also assessed. With a 73% recruitment rate, the sample was representative of patients at participating hospitals: male, 51%; non-Hispanic Caucasian, 48%; African American, 23%; other race-ethnicity, 29%; and employed, 21%. Most (66%) had co-occurring disorders: substance use disorder, 61%; bipolar disorder, 32%; nonaffective psychosis, 27%; PTSD, 39%; unipolar depression, 27%; and ADHD, 28%. Before hospitalization, participants averaged 17610 cigarettes per day and had smoked for 19614 years, with moderate dependence (FTCD score, 562 out of possible 10); 30% did not intend to quit in the near future (precontemplation), 47% intended to quit in six months (contemplation), and 24% were preparing to quit in the next month. In multivariate regression models adjusting for age, sex, race-ethnicity, income, education, hospital site (academic ps.psychiatryonline.org
443
