THURSDAY, Feb. 16 -- The loss of a loved one can trigger deep emotional turmoil, but is the grief that follows a normal part of being human or is it a form of mental illness in need of diagnosis and treatment?

That's the gist of a major debate now unfolding in the world of psychiatry, as the American Psychiatric Association (APA) prepares to issue the fifth edition of its seminal reference guide to mental disease, the Diagnostic and Statistical Manual of Mental Disorders (DSM).

The issue: For the first time, the manual -- a touchstone for mental health professionals across the United States -- may not exclude the concept of "bereavement" from the constellation of behaviors and experiences that it deems worthy of consideration when clinicians set out to diagnose a major depressive disorder.

What does this mean? That feelings or outbursts accompanying the passing of a family member or close friend -- such as crying, insomnia, fatigue, confusion and profound sadness -- may now be viewed as a treatable illness rather than as a normal reaction to life's most shattering moments.

Needless to say, not everyone agrees with this shift in thinking.

"To me, grief is a normal condition, not to be tagged with a diagnostic code and to be treated," stressed Dr. T. Byram Karasu, chairman of psychiatry and behavioral sciences at Albert Einstein College of Medicine and psychiatrist-in-chief at Montefiore Medical Center in New York City. "Everyone loses someone in their lives at some point. So, this would be classifying everyone at some point. No one would be immune to this."

"And that does not make sense, because grief is a normal and very healthy behavior," said Karasu, who also chairs the APA's National Task Force on the treatment of depression. "One has to feel joy as well as pain and depression, otherwise life is not worth living. And one should not interrupt the grieving by medication or psychotherapy. You have to feel the loss, and only by feeling the loss and recovering from it will the person become a better person. Interrupted grief will remain unfinished business."

Karasu's stance is in line with those expressed by the editorial board of the British medical journal The Lancet, which lays out its opposition to the new clinical approach in its Feb. 18 issue.

"Grief is not an illness," the journal's editors argue, noting that a diagnostic change in the APA's forthcoming manual would empower clinicians to interpret any post-loss despair that endures beyond a two-week window as a troubling sign of sickness rather than a standard sign of coping.

The Lancet team suggests that, instead, an intense but normal bout of grief can last six months to a year, depending on the very individualized nature of the particular relationship that has been severed by death.

"Medicalising grief, so that treatment is legitimized routinely with antidepressants, for example, is not only dangerously simplistic, but also flawed," the authors noted.

They acknowledged, however, that sometimes grief can morph into something much more complicated, longer lasting and "pathological." In such instances, true clinical depression may ensue along the lines of a so-called "prolonged grief disorder," a potentially new designation now under consideration by the World Health Organization. And such patients, the board agreed, might stand to benefit from some form of mental health intervention.

The concern over exactly when normal grief becomes a condition that perhaps requires treatment is what's driving the notion of inclusion in the DSM, said University of California, San Diego, psychiatry professor Dr. Sidney Zisook.

"It is well recognized that the death of a loved one, just like any other serious stressor, [such as the] loss of a job, diagnosis of a fatal illness, divorce can trigger a clinical depression," he said. "The ensuing depressive syndromes are no less severe or debilitating when brought on by bereavement as they are after any other life event or, indeed, when the depression seems to occur out of the blue."

"Acknowledging that bereavement can be a severe stressor that may trigger a clinical depression in a vulnerable person does not medicalize or pathologize grief," he suggested. "Rather, it prevents clinical depression from being overlooked or ignored, and facilitates the possibility of appropriate treatment."

"This acknowledgment," Zisook cautioned, "does not mean that we think acute grief should end in days, weeks or even months. For some, it may last for years, whether or not there is also a clinical depression. But, acknowledging that clinical depression may also be present in some bereaved individuals may go a long way towards helping those individuals get on with their lives."

For University of Michigan Medical School psychiatry professor Dr. Randolph M. Nesse, the debate boils down to a tug-of-war between basic common sense on the one hand and science's search for diagnostic consistency on the other.

"Everyone knows that grief is something that happens to everybody," he noted. "And just because an emotion feels bad doesn't mean it's wrong or unhealthy. Most often it's a common-sense response to a real problem."

"So, my take is that it would be senseless to eliminate the grief exclusion [from the DSM]," said Nesse, who is also a professor of psychology at UM's College of Literature, Science and the Arts. "But, because it can be so damn hard to figure out when an emotion is normal or not normal without really knowing what is going on in a person's life, there are undeniable advantages to having a neat, clean, simple check-box kind of classification system for diagnosing depression. It makes it easier. So, you include grief as a box to tick, whether or not there is a real problem to be diagnosed."

"But that is what is so troubling," he added. "Because when someone gets a diagnosis of depression it then encourages giving that person treatment. And the getting of that treatment then pushes the person being treated into believing they do indeed have a problem that needs treatment to begin with. And that can be very unhelpful in many, many cases in which grief is really a normal and healthy response to a life event."

SOURCES: Sidney Zisook, M.D., professor, psychiatry, University of California, San Diego; T. Byram Karasu, M.D., chairman, chairman of psychiatry and behavioral sciences at Albert Einstein College of Medicine and psychiatrist-in-chief at Montefiore Medical Center in New York City, New York City; Randolph M. Nesse, M.D., professor, psychiatry, University of Michigan Medical School, and professor, psychology, University of Michigan College of Literature, Science and the Arts, Ann Arbor; Feb. 18, 2012, The Lancet

FRIDAY, Feb. 10 -- Most children and teens who deliberately injure themselves are discharged from emergency rooms without an evaluation of their mental health, a new study shows.

The findings are worrisome since risk for suicide is greatest right after an episode of deliberate self-harm, according to researchers at Nationwide Children's Hospital in Columbus, Ohio.

The researchers also found the majority of these kids do not receive any follow-up care with a mental health professional up to one month after their ER visit.

"Emergency department personnel can play a unique role in suicide prevention by assessing the mental health of patients after deliberate self-harm and providing potentially lifesaving referrals for outpatient mental health care," said lead study author Jeff Bridge, principal investigator at the hospital's Center for Innovation in Pediatric Practice, in a news release. "However, the coordination between emergency services for patients who deliberately harm themselves and linkage with outpatient mental health treatment is often inadequate."

For the study in the Journal of the American Academy of Child & Adolescent Psychiatry, researchers examined Medicaid data for adolescents aged 10 to 19 years. Only 39 percent of the patients discharged after trying to harm themselves received a mental health assessment in the emergency department.

Only about half of the children who had visited the ER for a mental health-related reason within the previous 60 days received a mental health evaluation during their visit to the ER for self-harm.

Up to 90 percent of young people who deliberately harm themselves meet criteria for at least one psychiatric disorder, particularly mood disorders, the researchers said.

The U.K.'s National Institute for Health and Clinical Excellence recommends that people who show up in an emergency room for self-harm should receive a mental health evaluation before being released from the hospital.

"This study highlights the need for strategies to promote emergency department mental health assessments, strengthening the training of physicians in pediatric mental health and adolescent suicide prevention and timely transitions to outpatient mental health care," Bridge said.

-- Mary Elizabeth Dallas

SOURCE: Nationwide Children's Hospital, news release, Jan. 30, 2012

TUESDAY, Feb. 7 -- Using Facebook can be bad for people with low self-esteem, a new study suggests.

Canadian researchers found people with low self-esteem deluge their Facebook friends with negative details about their lives, which makes them less likeable.

The findings, published online Feb. 7 in the journal Psychological Science, were unexpected, according to the researchers.

Many people with low self-esteem are uncomfortable sharing their thoughts and feelings face-to-face, but Facebook enables them to do this remotely, explained study author Amanda Forest, a graduate student at the University of Waterloo, in Ontario.

"We had this idea that Facebook could be a really fantastic place for people to strengthen their relationships," Forest said in a journal news release.

However, while people with low self-esteem may feel safer making personal disclosures on Facebook, doing so may actually cause them social harm.

"If you're talking to somebody in person and you say something, you might get some indication that they don't like it, that they're sick of hearing your negativity," Forest said.

But when people have a negative reaction to a post on Facebook, they tend to keep it to themselves.

"On Facebook, you don't see most of the reactions," Forest said.

-- Robert Preidt

SOURCE: Psychological Science, news release

TUESDAY, Jan. 31 -- Testosterone makes people more self-centered and less cooperative, a finding that may explain why group decisions can be affected by dominant individuals, researchers report.

Their study included 34 females who had never met. The women were divided into 17 pairs and asked to complete a series of tasks designed to assess their levels of cooperation. The tests were conducted on two separate days. On one day both women received a testosterone supplement. On the other day, they were given a placebo.

As expected, cooperation helped the pairs perform much better on the tasks than when individuals worked alone. Cooperation was normal when the women received the placebo, but was much less common after the women received the testosterone supplement, the investigators found.

Increased levels of testosterone were associated with the women behaving egocentrically and deciding in favor of their own selection over their partner's, said the researchers at the Wellcome Trust Center for Neuroimaging at University College London in England.

The findings were published in the Jan. 31 issue of the journal Proceedings of the Royal Society B.

"When we are making decisions in groups, we tread a fine line between cooperation and self-interest: too much cooperation and we may never get our way, but if we are too self-orientated, we are likely to ignore people who have real insight," study author Dr. Nick Wright said in a center news release.

"Our behavior seems to be moderated by our hormones -- we already know that oxytocin can make us more cooperative, but if this were the only hormone acting on our decision-making in groups, this would make our decisions very skewed," Wright explained.

"We have shown that in fact testosterone also affects our decisions, by making us more egotistical. Most of the time, this allows us to seek the best solution to a problem, but sometimes, too much testosterone can help blind us to other people's views," Wright noted. "This can be very significant when we are talking about a dominant individual trying to assert his or her opinion in, say, a jury."

Testosterone is naturally secreted in both men and women. Previous research suggests that testosterone influences a number of social behaviors. For example, female prisoners with higher levels of testosterone have been found to be more anti-social and more aggressive.

-- Robert Preidt

SOURCE: Wellcome Trust, news release, Jan. 31, 2012