You’ve Got Questions? We’ve Got Answers!
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From Cucumbers To Kindles
Q: Where do I get cucumber extract?
A: You can buy it from BulkSupplements.com (who, despite their name, start at 100g packs)
Alternatively: you want it as a topical ointment (for skin health) rather than as a dietary supplement (for bone and joint health), you can extract it yourself! No, it’s not “just juice cucumbers”, but it’s also not too tricky.
Click Here For A Quick How-To Guide!
Q: Tips for reading more and managing time for it?
A: We talked about this a little bit in yesterday’s edition, so you may have seen that, but aside from that:
- If you don’t already have one, consider getting a Kindle or similar e-reader. They’re very convenient, and also very light and ergonomic—no more wrist strain as can occur with physical books. No more eye-strain, either!
- Consider making reading a specific part of your daily routine. A chapter before bed can be a nice wind-down, for instance! What’s important is it’s a part of your day that’ll always, or at least almost always, allow you to do a little reading.
- If you drive, walk, run, or similar each day, a lot of people find that’s a great time to listen to an audiobook. Please be safe, though!
- If your lifestyle permits such, a “reading retreat” can be a wonderful vacation! Even if you only “retreat” to your bedroom, the point is that it’s a weekend (or more!) that you block off from all other commitments, and curl up with the book(s) of your choice.
Q: Any study tips as we approach exam season? A lot of the productivity stuff is based on working life, but I can’t be the only student!
A: We’ve got you covered:
- Be passionate about your subject! We know of no greater study tip than that.
- Find a willing person and lecture them on your subject. When one teaches, two learn!
- Your mileage may vary depending on your subject, but, find a way of studying that’s fun to you!
- If you can get past papers, get as many as you can, and use those as your “last minute” studying in the week before your exam(s). This will prime you for answering exam-style questions (and leverage state-dependent memory). As a bonus, it’ll also help ease any anxiety, because by the time of your exam it’ll be “same old, same old”!
Q: Energy drinks for biohacking, yea or nay?
A: This is definitely one of those “the dose makes the poison” things!
- Caffeine, in and of itself, can be healthy in moderation for most people.
- Taurine has assorted benefits at safe dosages:
- Other ingredients often have health benefits too.
But… The generally agreed safe dose of taurine is around 3g/day for most people; a standard Red Bull contains 1g.
That math would be simple, but… if you eat meat (including poultry or fish), that can also contain 10–950mg per 100g. For example, tuna is at the high end of that scale, with a standard 12oz (340g) tin already containing up to 3.23g of taurine!
And sweetened carbonated beverages in general have so many health issues that it’d take us a full article to cover them.
Short version? Enjoy in moderation if you must, but there are definitely better ways of getting the benefits they may offer.
Q: Best morning routine?
A: The best morning routine is whatever makes you feel most ready to take on your day!
This one’s going to vary a lot—one person’s morning run could be another person’s morning coffee and newspaper, for example.
In a nutshell, though, ask yourself these questions:
- How long does it take me to fully wake up in the morning, and what helps or hinders that?
- When I get out of bed, what do I really need before I can take on my day?
- If I could have the perfect morning, what would it look like?
- What can evening me do, to look after morning me’s best interests? (Semi-prepare breakfast ready? Lay out clothes ready? Running shoes? To-Do list?)
Q: I’m curious how much of these things you actually use yourselves, and are there any disagreements in the team? In a lot of places things can get pretty heated when it’s paleo vs vegan / health benefits of tea/coffee vs caffeine-abstainers / you need this much sleep vs rise and grinders, etc?
A: We are indeed genuinely enthusiastic about health and productivity, and that definitely includes our own! We may or may not all do everything, but between us, we probably have it all covered. As for disagreements, we’ve not done a survey, but if you take an evidence-based approach, any conflict will tend to be minimized. Plus, sometimes you can have the best of both!
- You could have a vegan paleo diet (you’d better love coconut if you do, though!
- There is decaffeinated coffee and tea (your taste may vary)
- You can get plenty of sleep and rise early (so long as an “early to bed, early to rise” schedule suits you!)
Interesting note: humans are social creatures on an evolutionary level. Evolution has resulted in half of us being “night owls” and the other half “morning larks”, the better to keep each other safe while sleeping. Alas, modern life doesn’t always allow us to have the sleep schedule that’d suit each of us best individually!
Have a question you’d like answered? Reply to this email, or use the feedback widget at the bottom! We always love to hear from you
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A New $16,000 Postpartum Depression Drug Is Here. How Will Insurers Handle It?
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A much-awaited treatment for postpartum depression, zuranolone, hit the market in December, promising an accessible and fast-acting medication for a debilitating illness. But most private health insurers have yet to publish criteria for when they will cover it, according to a new analysis of insurance policies.
The lack of guidance could limit use of the drug, which is both novel — it targets hormone function to relieve symptoms instead of the brain’s serotonin system, as typical antidepressants do — and expensive, at $15,900 for the 14-day pill regimen.
Lawyers, advocates, and regulators are watching closely to see how insurance companies will shape policies for zuranolone because of how some handled its predecessor, an intravenous form of the same drug called brexanolone, which came on the market in 2019. Many insurers required patients to try other, cheaper medications first — known as the fail-first approach — before they could be approved for brexanolone, which was shown in early trials reviewed by the FDA to provide relief within days. Typical antidepressants take four to six weeks to take effect.
“We’ll have to see if insurers cover this drug and what fail-first requirements they put in” for zuranolone, said Meiram Bendat, a licensed psychotherapist and an attorney who represents patients.
Most health plans have yet to issue any guidelines for zuranolone, and maternal health advocates worry that the few that have are taking a restrictive approach. Some policies require that patients first try and fail a standard antidepressant before the insurer will pay for zuranolone.
In other cases, guidelines require psychiatrists to prescribe it, rather than obstetricians, potentially delaying treatment since OB-GYN practitioners are usually the first medical providers to see signs of postpartum depression.
Advocates are most worried about the lack of coverage guidance.
“If you don’t have a published policy, there is going to be more variation in decision-making that isn’t fair and is less efficient. Transparency is really important,” said Joy Burkhard, executive director of the nonprofit Policy Center for Maternal Mental Health, which commissioned the study.
With brexanolone, which was priced at $34,000 for the three-day infusion, California’s largest insurer, Kaiser Permanente, had such rigorous criteria for prescribing it that experts said the policy amounted to a blanket denial for all patients, according to an NPR investigation in 2021.
KP’s written guidelines required patients to try and fail four medications and electroconvulsive therapy before they would be eligible for brexanolone. Because the drug was approved only for up to six months postpartum, and trials of typical antidepressants take four to six weeks each, the clock would run out before a patient had time to try brexanolone.
An analysis by NPR of a dozen other health plans at the time showed Kaiser Permanente’s policy on brexanolone to be an outlier. Some did require that patients fail one or two other drugs first, but KP was the only one that recommended four.
Miriam McDonald, who developed severe postpartum depression and suicidal ideation after giving birth in late 2019, battled Kaiser Permanente for more than a year to find effective treatment. Her doctors put her on a merry-go-round of medications that didn’t work and often carried unbearable side effects, she said. Her doctors refused to prescribe brexanolone, the only FDA-approved medication specifically for postpartum depression at the time.
“No woman should suffer like I did after having a child,” McDonald said. “The policy was completely unfair. I was in purgatory.”
One month after NPR published its investigation, KP overhauled its criteria to recommend that women try just one medication before becoming eligible for brexanolone.
Then, in March 2023, after the federal Department of Labor launched an investigation into the insurer — citing NPR’s reporting — the insurer revised its brexanolone guidelines again, removing all fail-first recommendations, according to internal documents recently obtained by NPR. Patients need only decline a trial of another medication.
“Since brexanolone was first approved for use, more experience and research have added to information about its efficacy and safety,” the insurer said in a statement. “Kaiser Permanente is committed to ensuring brexanolone is available when physicians and patients determine it is an appropriate treatment.”
“Kaiser basically went from having the most restrictive policy to the most robust,” said Burkhard of the Policy Center for Maternal Mental Health. “It’s now a gold standard for the rest of the industry.”
McDonald is hopeful that her willingness to speak out and the subsequent regulatory actions and policy changes for brexanolone will lead Kaiser Permanente and other health plans to set patient-friendly policies for zuranolone.
“This will prevent other women from having to go through a year of depression to find something that works,” she said.
Clinicians were excited when the FDA approved zuranolone last August, believing the pill form, taken once a day at home over two weeks, will be more accessible to women compared with the three-day hospital stay for the IV infusion. Many perinatal psychiatrists told NPR it is imperative to treat postpartum depression as quickly as possible to avoid negative effects, including cognitive and social problems in the baby, anxiety or depression in the father or partner, or the death of the mother to suicide, which accounts for up to 20% of maternal deaths.
So far, only one of the country’s six largest private insurers, Centene, has set a policy for zuranolone. It is unclear what criteria KP will set for the new pill. California’s Medicaid program, known as Medi-Cal, has not yet established coverage criteria.
Insurers’ policies for zuranolone will be written at a time when the regulatory environment around mental health treatment is shifting. The U.S. Department of Labor is cracking down on violations of the Mental Health Parity and Addiction Equity Act of 2008, which requires insurers to cover psychiatric treatments the same as physical treatments.
Insurers must now comply with stricter reporting and auditing requirements intended to increase patient access to mental health care, which advocates hope will compel health plans to be more careful about the policies they write in the first place.
In California, insurers must also comply with an even broader state mental health parity law from 2021, which requires them to use clinically based, expert-recognized criteria and guidelines in making medical decisions. The law was designed to limit arbitrary or cost-driven denials for mental health treatments and has been hailed as a model for the rest of the country. Much-anticipated regulations for the law are expected to be released this spring and could offer further guidance for insurers in California setting policies for zuranolone.
In the meantime, Burkhard said, patients suffering from postpartum depression should not hold back from asking their doctors about zuranolone. Insurers can still grant access to the drug on a case-by-case basis before they formalize their coverage criteria.
“Providers shouldn’t be deterred from prescribing zuranolone,” Burkhard said.
This article is from a partnership that includes KQED, NPR and KFF Health News.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
Subscribe to KFF Health News’ free Morning Briefing.
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Can You Repair Your Own Teeth At Home?
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It’s Q&A Day at 10almonds!
Have a question or a request? We love to hear from you!
In cases where we’ve already covered something, we might link to what we wrote before, but will always be happy to revisit any of our topics again in the future too—there’s always more to say!
As ever: if the question/request can be answered briefly, we’ll do it here in our Q&A Thursday edition. If not, we’ll make a main feature of it shortly afterwards!
So, no question/request too big or small 😎
❝I liked your article on tooth remineralization, I saw a “home tooth repair kit”, and wondered if it is as good as what dentists do, or at least will do the job well enough to save a dentist visit?❞
Firstly, for any wondering about the tooth remineralization, here you go:
Tooth Remineralization: How To Heal Your Teeth Naturally
Now, to answer your question, we presume you are talking about something like this kit available on Amazon. In which case, some things to bear in mind:
- This kind of thing is generally intended as a stop-gap measure until you see a dentist, because you cracked your tooth or lost a filling or something today, and will see the dentist next week, say.
- This kind of thing is not what Dr. Michelle Jorgensen was talking about in another video* that we wrote about; rather, it is using a polymer filler to rebuild what is missing. The key difference is: this is using plastic, which is not what your teeth are made of, so it will never “take” as part of the tooth, as some biomimetic dentistry options can do.
- Yes, this does also mean you are putting microplastics (because the powder is usually micronized polymer beads with zinc oxide, to which you add a liquid to create a paste that will set) in your mouth and quite possibly right next to an open blood supply depending on what’s damaged and whether capillaries were reaching it.
- Because of the different material and application method, the adhesion is nothing like professional fillings (be they metal or resin), and thus the chances of it coming out again or so high that it’s more a question of when, rather than if.
- If you have damage under there (as we presume you do in any scenario where you are using this), then if it’s not professionally cleaned before the filling goes in, then it can get infected, and (less dramatically, but still importantly) any extant decay can also get worse. We say “professionally”, because you will not be able to do an adequate job with your toothbrush, floss, etc at home, and even if you got dentist’s tools (which you can buy, by the way, but we don’t recommend), you will no more be able to do the same quality job as a dentist who has done that many times a day every day for the past 20 years, as buying expensive paintbrushes would make you able to restore a Renaissance painting without messing it up.
*See: Dangers Of Root Canals And Crowns, & What To Do Instead ← what she recommends instead is biomimetic dentistry, which is also more prosaically called “conservative restorative dentistry”, i.e. it tries to conserve as much as possible, replace lost material on a like-for-like basis, and generally end up with a result that’s as close to natural as possible.
In other words, the short answer to your question is “no, sorry, it isn’t and it won’t”
However! A just like it’s good to have a first aid kit in the house even if it won’t do the same job as an ambulance crew, it can be good to have a tooth repair kit (essentially, a tooth first-aid kit) in the house, precisely to use it just as a stop-gap measure in the event that you one day crack a tooth or lose a filling or such, and don’t want to leave it open to all things in the meantime.
(The results of this sort of kit are so not long-term in nature that it will be quick and easy for your dentist to remove it to do their own job once you get there)
If in doubt, always see your dentist as soon as possible, as many things are a lot less work to treat now, than to treat later. Just, make sure to advocate for yourself and what you actually want/need, and don’t let them upsell you on something you didn’t come in for while you’re sitting in their chair—that’s a conversation to be had in advance with a clear head and no pressure (and nobody’s hands in your mouth)!
See also: Dentists Are Pulling ‘Healthy’ and Treatable Teeth To Profit From Implants, Experts Warn
Take care!
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How To Reduce Your Alzheimer’s Risk
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Reduce Your Alzheimer’s Risk
Alzheimer’s is just one cause of dementia, but it’s a very notable one, not least of all because it’s
- a) the most common cause of dementia, and
- b) a measurably terminal disease.
For that reason we’re focusing on Alzheimer’s today, although most of the advice will go for avoiding dementia in general.
First, some things not everyone knows about Alzheimer’s:
- Alzheimer’s is a terminal disease.
- People who get a diagnosis at age 60 are typically given 4–8 years to live.
- Some soldier on for as many as 20, but those are rare outliers.
- Alzheimer’s begins 20 years or more before other symptoms start to develop.
- This makes this information very relevant for younger people approaching 40, for example.
- Alzheimer’s accounts for 60–80% of dementia, and affects around 6% of people over 60.
- By the age of 65, that figure is 10%. By the age of 70, however, the percentage is still about the same—this is because of the mortality rate preventing the accumulation of Alzheimer’s patients over time.
Want to know more? Read: 2023 Alzheimer’s Disease Facts And Figures Special Report ← this is a very comprehensive downloadablereference, by the way, including a lot of information about diagnosis, treatmentpathways, and earlyinterventions.
Speaking of diagnosis…
Know what the symptoms are… and aren’t!
Forgetting your car keys can be frustrating. Forgetting them frequently can be worrying.
But: there’s a difference between forgetting your car keys, and forgetting what car keys are used for. The latter is the kind of memory loss that’s more of a red flag for Alzheimer’s.
Similarly: forgetting someone’s name can be embarrassing. Forgetting someone’s name, asking them, forgetting asking them, asking them again, forgetting again (lather rinse repeat) is more of a red flag for Alzheimer’s.
There are other symptoms too, some of them less commonly known:
❝Difficulty remembering recent conversations, names or events; apathy; and depression are often early symptoms. Communication problems, confusion, poor judgment and behavioral changes may occur next. Difficulty walking, speaking, and swallowing are common in the late stages of the disease❞
If you or a loved one are experiencing worrying symptoms: when it comes to diagnosis and intervention, sooner is a lot better than later, so do talk to your doctor.
As for reducing your risk? First, the obvious stuff:
The usual 5 things that go for almost everything:
- Have a good diet—the Mediterranean Diet is once again recommended (we expect this will not be a surprise to regular readers!)
- Get regular exercise—in the case of avoiding Alzheimer’s and other dementias, typically the most important thing here is heart health, so getting regular cardiovascular exercise, such walking, running, or dancing is great. Cycling too. Swimming, not so much. Not that swimming’s bad or anything, it’s just that when your body is horizontal, the heart has less work to do, especially in the upper part of the body, because it’s not defying gravity. Similarly, yoga is great for the health but won’t particularly help with this, nor will weight training.
- Get good sleep—as we get older, we tend to need less sleep, and tend more towards the lower end of the standard “7–9 hours” prescription, but getting at least those 7 hours makes a huge difference.
- Cut down (or eliminate) alcohol consumption—and especially avoid binge-drinking. While “binge-drinking” is typically associated with young people, that Christmas party where that one uncle gets very drunk is also binge-drinking, for example. Plus, heavy drinking in early life has also been correlated with higher risk of Alzheimer’s later.
- Don’t smoke. It’s bad for everything, and Alzheimer’s risk is no exception.
How much do lifestyle changes alone make a difference?
They make a big difference. This 2022 population-based cohort study (so: huge sample size) looked at people who had 4–5 of the healthy lifestyle factors being studied, vs people who had 0–1 of them. They found:
❝A healthy lifestyle was associated with a longer life expectancy among men and women, and they lived a larger proportion of their remaining years without Alzheimer’s dementia.❞
The numbers of years involved by the way ranged between 3 and 20 years, in terms of life expectancy and years without or with Alzheimer’s, with the average increase of healthy life years being approximately the same as the average increase in years. This is important, because:
A lot of people think “well if I’m going to go senile, I might as well [unhealthy choice that shortens lifespan]”, but they misunderstand a critical factor:
The unhealthy choices will reduce their healthy life years, and simply bring the unhealthy ones (and subsequent death) sooner. If you’re going to spend your last few years in ill-health, it’s better to do so at 90 than 50.
The other thing you may already know… And a thing about it that not everyone considers:
Keeping cognitively active is important. This much is broadly known by the general public, and to clinicians, this was the fourth “healthy factor” in the list of five (instead of the sleep that we put there, because we were listing the 5 things that go for most preventable health issues).
Everyone leaps to mention sudoku at this point, so if that’s your thing, great, enjoy it! (This writer personally enjoys chess, which isn’t everyone’s cup of tea; if it yours though, you can come join her on Chess.com and we’ll keep sharp together)
But the more parts of your mental faculties you keep active, the better. Remember, brainpower (as with many things in health and life) is a matter of “use it or lose it” and this is on a “per skill” basis!
What this means: doing sudoku (a number-based puzzle game) or chess (great as it may be) won’t help as much for keeping your language skills intact, for example. Given that language skills are one of the most impactful and key faculties to get lost to Alzheimer’s disease, neglecting such would be quite an oversight!
Some good ways to keep your language skills tip-top:
- Read—but read something challenging, if possible. It doesn’t have to be Thomas Scanlon’s What We Owe To Each Other, but it should be more challenging than a tabloid, for example. In fact, on the topic of examples:
- This newsletter is written to be easy to read, while not shying away from complex ideas or hard science. Our mission is literally to “make [well-sourced, science-based] health and productivity crazy simple”.
- But the academic papers that we link? Those aren’t written to be easy to read. Go read them, or at least the abstracts (in academia, an abstract is essentially an up-front summary, and is usually the first thing you’ll see when you click a link to a study or such). Challenge yourself!
- Write—compared to reading/listening, producing language is a (related, but) somewhat separate skill. Just ask any foreign language learner which is more challenging: reading or writing!
- Journaling is great, but writing for others is better (as then you’ll be forced to think more about it)
- Learn a foreign language—in this case, what matters it that you’re practicing and learning, so in the scale of easy to hard, or doesn’t matter if it’s Esperanto or Arabic. Duolingo is a great free resource that we recommend for this, and they have a wide range of extensive courses these days.
Now for the least obvious things…
Social contact is important.
Especially in older age, it’s easy to find oneself with fewer remaining friends and family, and getting out and about can be harder for everyone. Whatever our personal inclinations (some people being more introverted or less social than others), we are fundamentally a social species, and hundreds of thousands of years of evolution have built us around the idea that we will live our lives alongside others of our kind. And when we don’t, we don’t do as well.
See for example: Associations of Social Isolation and Loneliness With Later Dementia
If you can’t get out and about easily:
- Online socialising is still socializing.
- Online community is still community.
- Online conversations between friends are still conversations between friends.
If you don’t have much (or anyone) in the category of friends and family, join Facebook groups related to your interests, for example.
Berries are surprisingly good
^This may read like a headline from 200,000 BCE, but it’s relevant here!
Particularly recommended are:
- blueberries
- blackberries
- raspberries
- strawberries
- cranberries
We know that many of these berries seem to have a shelf-life of something like 30 minutes from time of purchase, but… Frozen and dried are perfectly good nutritionally, and in many cases, even better nutritionally than fresh.
Read: Effect of berry-based supplements and foods on cognitive function: a systematic review
Turmeric’s health benefits appear to include protecting against Alzheimer’s
Again, this is about risk reduction, and turmeric (also called curcumin, which is not the same as cumin) significantly reduces the build-up of amyloid plaques in the brain. Amyloid plaques are part of the progression of Alzheimer’s.
See for yourself: Protective Effects of Indian Spice Curcumin Against Amyloid Beta in Alzheimer’s Disease
If you don’t like it as a spice (and even if you do, you probably don’t want to put it in your food every day), you can easily get it as a supplement in capsule form.
Lower your homocysteine levels
Lower our what now? Homocysteine is an amino acid used for making certain proteins, and it’s a risk factor for Alzheimer’s.
Foods high in folate (and possible other B-vitamins) seem to lower homocysteine levels. Top choices include:
- Leafy greens
- Cruciferous vegetables
- Tomatoes
Get plenty of lutein
We did a main feature about specifically this a little while ago, so we’ll not repeat our work here, but lutein is found in, well, the same things we just listed above, and lower levels of lutein are associated with Alzheimer’s disease. It’s not a proven causative factor—we don’t know entirely what causes Alzheimer’s, just a lot of factors that have a high enough correlation that it’d be remiss to ignore them.
Catch up on our previous article: Brain Food? The Eyes Have It
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Peanuts vs Macadamias – Which is Healthier?
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Our Verdict
When comparing peanuts to macadamias, we picked the peanuts.
Why?
In terms of macros, peanuts have more than 3x the protein while macadamias have a lot more fat. It’s mostly healthy monounsaturated fat, but all the same, we’ll prioritize the protein over the fat, which becomes the deciding factor since they are approximately equal on carbs and fiber. So, a subjective win for peanuts in this category.
In the category of vitamins, peanuts have a lot more of vitamins B3, B5, B6, B9, E, and choline, while macadamias have slightly more of vitamins B1, B2, and C. A clear and convincing win for peanuts.
When it comes to minerals, peanuts have more calcium, copper, iron, magnesium, phosphorus, potassium, selenium, and zinc, while macadamias have more manganese. An overwhelming win for peanuts.
Adding up the sections with their various degrees of win for peanuts, makes for an overall absolute win for peanuts, but by all means enjoy either or both; diversity is good!
Want to learn more?
You might like to read:
Why You Should Diversify Your Nuts
Enjoy!
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How Not To Die – by Dr. Michael Greger
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We previously reviewed this book some years ago, but we’re revisiting it now because:
- It really is a book that should be in every healthspan-enjoyer’s collection
- Our book reviews back then were not as comprehensive as now (though we still generally try to fit into the “it takes about one minute to read this review” idea, sometimes we’ll spend a little extra time).
Dr. Greger (of “Dr. Greger’s Daily Dozen” fame) outlines for us in cold hard facts and stats what’s most likely to be our cause of death. While this is not a cheery premise for a book, he then sets out to work back from there—what could have prevented those specific things?
Thus, while the book doesn’t confer immortality (the title is not “how to not die”, after all), it does teach us how not to die—i.e, from heart disease, lung diseases, brain diseases, digestive cancers, infections, diabetes, high blood pressure, liver disease, blood cancers, kidney disease, breast cancer, suicidal depression, prostate cancer, Parkinson’s disease, and even iatrogenic causes.
This it does with a lot of solid science, explained for the layperson, and/but without holding back when it comes to big words, and a lot of them, at that. If you want to add in daily exercises, just lifting the book could be a start; weighing in at 678 pages, it’s an information-dense tome that’s more likely to be sifted through than read cover-to-cover.
The style is thus dense science somewhat editorialized for lay readability, and well-evidenced with around 3,000 citations. That’s not a typo; there are 178 pages of bibliography at the back with about 15–20 scientific references per page.
In terms of practical use, he does also devote chapters to that, it’s not just all textbook. Indeed, he discusses the reasonings behind the items, portion sizes, and quantities of his “daily dozen” foods, so that the reader will understand how much bang-for-buck they deliver, and then it’ll seem a lot less like an arbitrary list, and more likely to be adopted and maintained.
Bottom line: if you care about not getting life-threatening illnesses (which at the end of the day, come to most people at some point), then this book is a must-read.
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Prolonged Grief: A New Mental Disorder?
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The issue is not whether certain mental conditions are real—they are. It is how we conceptualize them and what we think treating them requires.
The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) features a new diagnosis: prolonged grief disorder—used for those who, a year after a loss, still remain incapacitated by it. This addition follows more than a decade of debate. Supporters argued that the addition enables clinicians to provide much-needed help to those afflicted by what one might simply consider a too much of grief, whereas opponents insisted that one mustn’t unduly pathologize grief and reject an increasingly medicalized approach to a condition that they considered part of a normal process of dealing with loss—a process which in some simply takes longer than in others.
By including a condition in a professional classification system, we collectively recognize it as real. Recognizing hitherto unnamed conditions can help remove certain kinds of disadvantages. Miranda Fricker emphasizes this in her discussion of what she dubs hermeneutic injustice: a specific sort of epistemic injustice that affects persons in their capacity as knowers1. Creating terms like ‘post-natal depression’ and ‘sexual harassment’, Fricker argues, filled lacunae in the collectively available hermeneutic resources that existed where names for distinctive kinds of social experience should have been. The absence of such resources, Fricker holds, put those who suffered from such experiences at an epistemic disadvantage: they lacked the words to talk about them, understand them, and articulate how they were wronged. Simultaneously, such absences prevented wrong-doers from properly understanding and facing the harm they were inflicting—e.g. those who would ridicule or scold mothers of newborns for not being happier or those who would either actively engage in sexual harassment or (knowingly or not) support the societal structures that helped make it seem as if it was something women just had to put up with.
For Fricker, the hermeneutical disadvantage faced by those who suffer from an as-of-yet ill-understood and largely undiagnosed medical condition is not an epistemic injustice. Those so disadvantaged are not excluded from full participation in hermeneutic practices, or at least not through mechanisms of social coercion that arise due to some structural identity prejudice. They are not, in other words, hermeneutically marginalized, which for Fricker, is an essential characteristic of epistemic injustice. Instead, their situation is simply one of “circumstantial epistemic bad luck”2. Still, Fricker, too, can agree that providing labels for ill-understood conditions is valuable. Naming a condition helps raise awareness of it, makes it discursively available and, thus, a possible object of knowledge and understanding. This, in turn, can enable those afflicted by it to understand their experience and give those who care about them another way of nudging them into seeking help.
Surely, if adding prolonged grief disorder to the DSM-5 were merely a matter of recognizing the condition and of facilitating assistance, nobody should have any qualms with it. However, the addition also turns intense grief into a mental disorder—something for whose treatment insurance companies can be billed. With this, significant forces of interest enter the scene. The DSM-5, recall, is mainly consulted by psychiatrists. In contrast to talk-therapists like psychotherapists or psychoanalysts, psychiatrists constitute a highly medicalized profession, in which symptoms—clustered together as syndromes or disorders—are frequently taken to require drugs to treat them. Adding prolonged grief disorder thus heralds the advent of research into various drug-based grief therapies. Ellen Barry of the New York Times confirms this: “naltrexone, a drug used to help treat addiction,” she reports, “is currently in clinical trials as a form of grief therapy”, and we are likely to see a “competition for approval of medicines by the Food and Drug Administration.”3
Adding diagnoses to the DSM-5 creates financial incentives for players in the pharmaceutical industry to develop drugs advertised as providing relief to those so diagnosed. Surely, for various conditions, providing drug-induced relief from severe symptoms is useful, even necessary to enable patients to return to normal levels of functioning. But while drugs may help suppress feelings associated with intense grief, they cannot remove the grief. If all mental illnesses were brain diseases, they might be removed by adhering to some drug regimen or other. Note, however, that ‘mental illness’ is a metaphor that carries the implicit suggestion that just like physical illnesses, mental afflictions, too, are curable by providing the right kind of physical treatment. Unsurprisingly, this metaphor is embraced by those who stand to massively benefit from what profits they may reap from selling a plethora of drugs to those diagnosed with any of what seems like an ever-increasing number of mental disorders. But metaphors have limits. Lou Marinoff, a proponent of philosophical counselling, puts the point aptly:
Those who are dysfunctional by reason of physical illness entirely beyond their control—such as manic-depressives—are helped by medication. For handling that kind of problem, make your first stop a psychiatrist’s office. But if your problem is about identity or values or ethics, your worst bet is to let someone reify a mental illness and write a prescription. There is no pill that will make you find yourself, achieve your goals, or do the right thing.
Much more could be said about the differences between psychotherapy, psychiatry, and the newcomer in the field: philosophical counselling. Interested readers may benefit from consulting Marinoff’s work. Written in a provocative, sometimes alarmist style, it is both entertaining and—if taken with a substantial grain of salt—frequently insightful. My own view is this: from Fricker’s work, we can extract reasons to side with the proponents of adding prolonged grief disorder to the DSM-5. Creating hermeneutic resources that allow us to help raise awareness, promote understanding, and facilitate assistance is commendable. If the addition achieves that, we should welcome it. And yet, one may indeed worry that practitioners are too eager to move from the recognition of a mental condition to the implementation of therapeutic interventions that are based on the assumption that such afflictions must be understood on the model of physical disease. The issue is not whether certain mental conditions are real—they are. It is how we conceptualize them and what we think treating them requires.
No doubt, grief manifests physically. It is, however, not primarily a physical condition—let alone a brain disease. Grief is a distinctive mental condition. Apart from bouts of sadness, its symptoms typically include the loss of orientation or a sense of meaning. To overcome grief, we must come to terms with who we are or can be without the loved one’s physical presence in our life. We may need to reinvent ourselves, figure out how to be better again and whence to derive a new purpose. What is at stake is our sense of identity, our self-worth, and, ultimately, our happiness. Thinking that such issues are best addressed by popping pills puts us on a dangerous path, leading perhaps towards the kind of dystopian society Aldous Huxley imagined in his 1932 novel Brave New World. It does little to help us understand, let alone address, the moral and broader philosophical issues that trouble the bereaved and that lie at the root not just of prolonged grief but, arguably, of many so-called mental illnesses.
Footnotes:
1 For this and the following, cf. Fricker 2007, chapter 7.
2 Fricker 2007: 152
3 Barry 2022
References:
Barry, E. (2022). “How Long Should It Take to Grieve? Psychiatry Has Come Up With an Answer.” The New York Times, 03/18/2022, URL = https://www.nytimes.com/2022/03/18/health/prolonged-grief-
disorder.html [last access: 04/05/2022])
Fricker, M. (2007). Epistemic Injustice. Power & the Ethics of knowing. Oxford/New York: Oxford University Press.
Huxley, A. (1932). Brave New World. New York: Harper Brothers.
Marinoff, L. (1999). Plato, not Prozac! New York: HarperCollins Publishers.Professor Raja Rosenhagen is currently serving as Assistant Professor of Philosophy, Head of Department, and Associate Dean of Academic Affairs at Ashoka University. He earned his PhD in Philosophy from the University of Pittsburgh and has a broad range of philosophical interests (see here). He wrote this article a) because he was invited to do so and b) because he is currently nurturing a growing interest in philosophical counselling.
This article is republished from OpenAxis under a Creative Commons license. Read the original article.
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