Contesting Depression

Statue of Hangin Man (Sigmund Freud) by David Cerny; Photo by sebi ryffel

Social disagreement about the medicalization of experience is intensifying. Psychiatrist Allen Frances complains that the draft DSM is too quick to pathologize grief:

A startling suggestion is buried in the fine print describing proposed changes for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders — perhaps better known as the D.S.M. 5, the book that will set the new boundary between mental disorder and normality. If this suggestion is adopted, many people who experience completely normal grief could be mislabeled as having a psychiatric problem.

Suppose your spouse or child died two weeks ago and now you feel sad, take less interest and pleasure in things, have little appetite or energy, can’t sleep well and don’t feel like going to work. In the proposal for the D.S.M. 5, your condition would be diagnosed as a major depressive disorder. . . .[This change] would give mentally healthy people the ominous-sounding diagnosis of a major depressive disorder, which in turn could make it harder for them to get a job or health insurance. . . .

Grieving is an unavoidable part of life — the necessary price we all pay for having the ability to love other people. Our lives consist of a series of attachments and inevitable losses, and evolution has given us the emotional tools to handle both.

Moving from the end of life to the beginning, another commentary mentions worries that quiet and listless preschoolers may be pigeonholed as depressed:

Today a number of child psychiatrists and developmental psychologists say depression can surface in children as young as 2 or 3. . . . [But c]lassifying preschool depression as a medical disorder carries a risk of disease-mongering. “Given the influence of Big Pharma, we have to be sure that every time a child’s ice cream falls off the cone and he cries, we don’t label him depressed,” cautions Rahil Briggs, an infant-toddler psychologist at Children’s Hospital at Montefiore in New York.

Though research does not support the use of antidepressants in children this young, medication of preschoolers, often off label, is on the rise. One child psychologist told me about a conference he attended where he met frustrated drug-industry representatives. “They want to give these kids medicines, but we can’t figure out the diagnoses.” As Daniel Klein warns, “Right now the problem may be underdiagnosis, but these things can flip completely.”

Both stories foreshadow larger struggles over the meaning of “health” in risk societies where there is less margin for error or “underperformance” at work or school. Virtually any wealthy New Yorker with small children has a story about the crucial “pre-school interviewing process,” where elite schools can use an hour-long interaction with a child to decide whether or not to accept him or her as a student. On the other end of the income scale, high unemployment means that at-will employees who can’t keep up an adequate reserve of chipper and helpful “can-do” spirit are always at risk of being sacrificed in favor of some member of the reserve corps of unemployed. Business can’t survive if it’s culture is “too nice.” And hiring may end up being driven by whether an “analysis by an organizational psychologist can tell the hirer whether an applicant will have a problem with the manager or team.”

Larger social currents are feeding anxieties about these trends. Some corporate mottos appear to be “get healthy, or else:”

“We have this notion that you can gorge on hot dogs, be in a pie-eating contest, and drink every day, and society will take care of you,” says Harvard Business School Professor Michael E. Porter, who co-authored Redefining Health Care. “We can’t afford to let individuals drive up costs because they’re not willing to address their health problems.”

Hence the wellness fixation at companies as varied as IBM, Microsoft, Harrah’s Entertainment, and Scotts. Employees who voluntarily sign up for such programs often receive discounts on health-care premiums, free weight-loss and smoking-cessation programs, gratis gym memberships, counseling for emotional problems, and prizes like vacations or points that can be redeemed for gift cards.

M. Todd Henderson assures us that “corporate nannies are superior to their state analogs in some cases,” in part because “corporate policies are subjected to more instantaneous feedback from labor markets, which reduces overreaching.” As unemployment climbs and benefits end, that “feedback from labor markets” gets weaker and weaker: employees take whatever job they can find.

What’s the end result of these trends? I can’t predict, but I think Gary Shteyngart’s recent satirical novel provides one template for the workplace of the future. His protagonist, Lenny Abramov, finds that his employer has placed “five gigantic Solari schedule boards” in the office. The boards:

[D]isplayed the names of . . . employees, along with the results of our latest physicals . . . our fasting insulin and triglycerides, and, most important, our ‘mood + stress indicators,’ which were always supposed to read ‘positive/playful/ready to contribute,’ but which, with enough input from competitive co-workers, could be changed to ‘one moody betch today” or ‘not a team playa this month.’ On this particular day . . . one unfortunate Aiden M. was lowered from ‘overcoming the loss of loved one’ to ‘letting personal life interfere with job.’ (57-58)

"'America Facing Its Most Tragic Moment' -- Dr. Carl Jung", New York Times (29 September 1912)

Ultimately, moods become health problems when they seriously interfere with activities of daily living, including family, work, spirituality, and play. What Shteyngart reminds us is that the demands of work are quite flexible, and always-evolving. Without a robust societal sense of the proper claims of grief and other emotions, economic imperatives are likely to shrink them inexorably. Unlike the film Gattaca, where extant social structures somehow persist in the wake of massive changes in enhancement technology, Shteyngart’s novel describes a world where relatively small changes in self-concept, media use, and aspiration in an elite can fundamentally destabilize societal expectations.

Given the current balance of power between labor and employers, the disciplinary impact of new technology is likely to rise. As Hannah Pitkin puts it, if we are not careful, the very tools invented to reduce suffering may end up increasing it, by making authorities less tolerant of human need:

We have developed astonishing techniques of communication, persuasion, indoctrination, organization. . . . Yet these extraordinary capacities somehow have not made people happy or free or even powerful. . . . We do not direct these, our alleged powers; if anything, they direct us and determine the conditions of our lives, developing with a momentum of their own in ways we cannot foresee and that are often obviously harmful to human life and civilization

The contestation of pre-school and post-death depression concerns fundamental questions about what it means to be human. Circumstances need to be better engineered to accommodate the normal range of human experience. Otherwise a Procrustean drift will result in humans better engineered to to accommodate their circumstances. As Jaron Lanier has written, “When people are told that a computer is intelligent, they become prone to changing themselves in order to make the computer appear to work better, instead of demanding that the computer be changed to become more useful” (36). Perhaps employers without “grief leave” policies should be changed more quickly than employees in search of non-medical solace.

Mintz Levin: “Health Care Reform Advisory: Assessing the Impact of Federal Health Care Reform on Employers and Employer-Sponsored Group Health Plans”

battage a fleau (threshing with flail) 1270 AD

I’ve written before on this blog about the value of Mintz Levin’s reports, and am about to do so again (you can find their  work, as a permanent link, under “Resources” on this blog). There is, linked below, a very nicely done recap of the health reform law– which gets quickly to the point regarding the implications of a number of provisions within the law for employers and employer-sponsored group health plans. For those of you unfamiliar, Mintz Levin is  a law firm with its primary office in D.C., and a health sciences group with a well deserved reputation for excellence. If you are an employer, or even an employee that has some appropriate notion of “trickle-down,” I highly recommend you take a look.

Written by Alden J. Bianchi and Patricia A. Moran, “Assessing the Impact of Federal Health Care Reform on Employers and Employer-Sponsored Group Health Plans,” may be found here.

More Employers Are Adopting Consumer-Directed Health Plans

Photo by liewcf via Flickr

As the cost of health care increases and employers continue to struggle in the bleak economy, many employers are said to be faced with a decision: whether to opt-out of their existing health plans, either by eliminating health benefits for their employees or finding a more cost-friendly alternative. CNN reports that more employers are offering consumer-directed health plans as what is considered a cost-friendly alternative.

CNN states:

More than 51% of U.S. employers now offer a consumer-directed health plan (CDHP), up from 47% last year, according to the latest survey of 489 large U.S. employers from Watson Wyatt, a consulting firm that specializes in employee benefits.

A CDHP is a way of lowering health plan costs of employers by shifting the costs of medical care to individual employees.  The article reports:

Consumer-directed health plans (CDHPs) are typically lower premium but higher deductible health plans. They feature a kind of savings or spending account that helps employees pay their out-of-pocket expenses for covered services, or services that are not covered by a traditional plan.

One form of popular CDHP is Catastrophic Health Insurance– in these plans, often taken out in conjunction  with a tax exempt Health Savings Account (HSA). Under IRS rules, according to Insurance.com “the total out-of-pocket maximum (which includes the deductible and co-payments) for these HSA-linked catastrophic health plans is $5,600 for singles, and $11,200 for families.” In addition, Insurance.com states

Certain pre-existing conditions, such as diabetes and mental health disorders, might mean you can’t qualify for an individual catastrophic health plan without prior qualifying group coverage, or at least that you can’t get coverage for those pre-existing conditions.

Finally, many CDHPs have “lifetime caps” of somewhere between 1 and 5 million dollars. When medical bills surpass these amounts the insurance company is no longer liable.

As the cost of health benefits and health care continues to increase, alternatives to the traditional cost-sharing relationship between the employer and employee are being examined– and understandably so. As for the relative merit of CDHPs and their “catastrophic” brethren, perhaps it depends upon which lens one looks through.

Proponents of CDHPs often cite the increased value in cost conscious “out of pocket” consumer health care choices and the positive affect this “true market” driven approach may have on the cost and quality of care; but the reality of the basis for consumer choice, as Frank Pasquale noted on this blog, is that “brand power has a lot more to do with choices here than objective assessment of outcomes.” In addition, as Professor Pasquale points out, Partners Health in Massachusetts was able to use its power, (market, brand, and sundry), in order to demand “reimbursements up to 30% over what other hospitals receive for identical procedures. Their market share has steadily increased as well, allowing them to stockpile the resources necessary to enter into new markets and threaten the viability of cheaper community hospitals.”

If CDHPs are viewed through the “better than nothing” lens, they obviously have some appeal (But See immediately above); if viewed through the “universal coverage” lens they obviously leave something to be desired. Having said all that, CDHPs may not be a best alternative, but they are becoming– in a woefully ironic twist of the word– a more “popular” alternative.