Distress: to treat or not to treat?

In one of our research group meetings, we took an informal poll to find out who would prescribe a benzodiazepine to someone who was acutely grieving, felt anxious, was experiencing some insomnia, and wanted relief from distress. The younger among us mostly would prescribe while those of us who are grizzled would mostly refrain from doing so. Coincidentally, within the next week, one of my patients called requesting exactly that. One of her parents had died and she was anticipating becoming overwhelmed. She was afraid that she would "lose control" at the funeral. To prevent this from happening, she asked if there was anything I could give her. While expressihg my sympathy for her loss, I told her that I did not have anything that would relieve her distress; the loss of a loved one is a painful part of the human condition for which no pill seemed appropriate. The research group discussion and the patient both bring .up important questions about the nature of distress, psychiatry, neuropsychiatry, and psychopharmacology. For clinicians, alleviating patients' suffering, decreasing pain and distress, and improving functioning are obvious laudable goals for psychiatry and neuropsychiatry. But these goals present concrete philosophical challenges for thoughtful clinicians. Patients present with a complaint that prompts them to seek help. Clinicians diagnose the problem and prescribe treatment. If the treatment works, patients' distress is decreased and the treatment is declared successful; the goals of treatment are reached. In many cases, this model works. A patient with an episode of major depression remits with an antidepressant and appropriate psychotherapy. Another patient with schizophrenia is freed of hallucinations and delusions, and is able to function. Yet another patient with seizures and post-ictal confusion is stabilized and can lead a normal life. But what about someone, like the patient described earlier, who is grieving the loss of a loved one and feeling almost intolerable anguish and painful yearning, and requests medication to lessen their distress? What about someone who is struggling with loneliness and intimacy issues, and feels anxious about developing relationships? What about someone who stays in a dysfunctional marriage and feels constantly dysphoric and empty? What about someone who learns that they have multiple sclerosis and mourns the loss of their future? In these instances, it is not so clear that clinicians can easily treat their patients' distress. Distress is defined as hurt, suffering, pain, anguish, torment (condensed in the marvelous Yiddish word tsoris—meaning troubles and suffering from those troubles). The spectrum of distress reflects the human condition. Causes of distress include loss of important people