“Have the psychiatrists gone mad? — those who weren’t crazy to begin with! They want to turn grief into a disease!”
This might well be the attitude of many in the general public, having read the misleading news coverage of a debate over the DSM-5 — the still-preliminary diagnostic classification of mental disorders, often referred to as “psychiatry’s Bible.” Now, I am no fan of the DSM model of diagnosis — in fact, if the DSM is the “bible,” I’m something of a heretic. In my view, the DSM’s superficial symptom checklists are great for research purposes, but not very useful for most clinicians or patients.
Nevertheless, I don’t like seeing the work of my DSM-5 colleagues misrepresented. So when I see bogus headlines like, “Grief Could Join List of Disorders” in the usually circumspect New York Times, I cringe.
Before discussing the arcane debate over the “bereavement exclusion,” it’s important to understand what most psychiatrists really believe about grief, bereavement, and depression.
No psychiatrist I know believes that grief is a disorder, disease, or abnormal condition that requires treatment. And nobody connected with the DSM-5 believes that either! Grief is ordinarily a useful, adaptive emotion that follows a major loss, such as the death of a loved one (bereavement) or the breakup of an intimate relationship.
Indeed, the 15th century monk, Thomas a Kempis, recognized that there are “proper sorrows of the soul,” and that “…we often engage in empty laughter when we should rightly weep.” Psychologist Kay R. Jamison — writing in the wake of her husband’s death — described grief as “…a generative and human thing… it acts to preserve the self.” (from Nothing Was the Same). Grief might be considered the price we pay for forming deep and intimate attachments.
It is true that following the death of a loved one, many bereaved individuals will show some signs or symptoms that overlap with those of clinical depression — what psychiatrists call major depressive disorder (MDD). In addition to feelings of intense sadness or anguish, the recently bereaved person may eat and sleep poorly for several weeks; have difficulty concentrating; and withdraw from most social activities.
But it’s important to note that most recently bereaved individuals will not meet the full DSM-IV criteria for a major depressive episode. Most are able to carry on their everyday functions and activities at a higher level than individuals with MDD. The current debate over the bereavement exclusion (BE) arises when someone who has lost a loved one within the past two months consults a doctor, and is noted to meet the full symptom and duration criteria for a major depressive disorder. To understand the implications of this, let’s consider two hypothetical scenarios:
“Mrs. Brown” is a 28-year-old mother of two, whose husband was killed in Afghanistan three weeks ago. She sees her family doctor and says, “I’m still in shock. Of course, I knew Bob was always at risk, but I still can’t believe it. I barely functioned at all for the first week after he died, then I dragged myself back to work at the office — but it’s really hard to concentrate on anything. God, I miss Bob so much! I’m taking care of the kids pretty well, but I am in so much pain, I cry almost every day. I keep seeing Bob’s face, his smile. Sometimes, I have wonderful memories of all the things we did together. I’m having a terrible time falling asleep, though, and I’m wondering if maybe I could get something for that? My appetite isn’t very good, either, and I don’t make any effort to go out and meet people. But I do appreciate it when friends call or drop by, though. I guess I’ll eventually get back to being my old self, and I do want to go on with life, but it’s really hard! What should I do, Doctor?”
Most good doctors will recognize Mrs. Brown as having the expected and “normal” grief that follows bereavement—and nothing we anticipate from the DSM-5 will change that. While some physicians might prescribe medication to help Mrs. Brown sleep, very few knowledgeable physicians would prescribe an antidepressant, assuming this is the totality of Mrs. Brown’s complaints. Based just on the information above, there is good reason to reassure Mrs. Brown that—with love, support, and enough time — she will get through this tragedy without professional help. Those diligent doctors who actually bother to pick up the DSM-IV (or the expected DSM-5) will discover that Mrs. Brown falls short of the criteria for a major depressive episode. Indeed, there is nothing anticipated from DSM-5 that would deny Mrs. Brown a diagnosis of “appropriate grief due to bereavement” or that would “label” her as having a mental disorder. Dropping the BE from DSM-5 would make no difference in a case like this, since the BE is an option only when the bereaved patient fully meets symptom and duration criteria for a major depressive episode within two months of a love one’s death.
Now let’s consider “Mr. Smith.” He is a 72-year-old retired businessman whose wife died of cancer three weeks ago. He visits his family doctor and says, “I feel down in the dumps and weepy every day, Doc—really lousy! I don’t get any pleasure out of anything anymore, even stuff I used to love, like watching football on TV. I wake up at 4 in the morning almost every day, and I have zero energy. I can’t keep my mind on anything. I barely eat, and I’ve lost 10 pounds since Mary passed away. I hate being around other people. And sometimes I feel like I didn’t really do enough for Mary when she was sick. God, how I miss her! I can still cook for myself, pay the bills, and so on, Doc, but I’m just going through the motions. I don’t enjoy life at all anymore.”
Though it’s still early after his wife’s death, wise and experienced clinicians will be very concerned about Mr. Smith. He easily meets DSM-IV and DSM-5 (draft) symptom and duration criteria for MDD. (A previous bout of MDD in his history would strengthen the likelihood, as would several other clinical findings I have omitted). And yet, under the current DSM-IV “rules,” Mr. Smith probably would not be diagnosed with a major depressive illness. He would simply be called “bereaved.” Why? Because he is still within the 2-month period that allows for use of the bereavement exclusion; and because — based on the facts presented — Mr. Smith doesn’t have the features that would “override” use of the BE, such as severe functional impairment, suicidal ideation, psychosis, morbid preoccupation with worthlessness, or extreme guilt. Ironically, if Mr. Smith’s wife had left him for another man, he would meet MDD criteria, using current DSM rules — go figure!
So, if the bereavement exclusion is retained in DSM-5, patients like Mr. Smith would likely be told, “You are just having a normal reaction to the death of your wife.” Probably, no treatment would be offered, and none covered by insurance. My colleagues and I believe this is a serious mistake, with potentially devastating consequences — including the risk of suicide.
Contrary to much fear-mongering in the press, our position does not imply that Mr. Smith should be started on an antidepressant. It means that the doctor should seriously consider a diagnosis of MDD; meet again with Mr. Smith in another 1-2 weeks; and consider the advisability of supportive psychotherapy. Medication could be an option if Mr. Smith significantly worsens or becomes suicidal. Combined “talk therapy” and medication would also be an option if he is much worse in a week or two. And, yes — some patients with Mr. Smith’s clinical picture may spontaneously improve within a few more weeks. That, of course, does not mean Mr. Smith’s grief will be at an end.