It’s been heating up now for the past few weeks as a charge led mainly by professionals. And it has caught the eye of the mainstream media. I’m talking about the revision process for the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5), the reference manual mental health professionals and researchers use to treat patients and design reliable research studies examining mental illness.
The latest upset? The fact that the new DSM-5 suggests that depression could co-occur with grief. Critics see the changes as suggesting the DSM is trying to “medicalize” normal grieving. Anyone who experiences grief after a tragic or significant loss will now be at risk for receiving — heaven forbid — mental health treatment and a diagnosis.
We’ve covered this ground here on more than one occasion, but it appears time to talk about whether depression can occur at the same time as grief or not. My first reaction was — grief is grief, depression is depression, and the two never really co-occur. But a few years ago, I read a piece here on World of Psychology by Dr. Ron Pies which completely changed my perspective.
Benedict Carey over at the New York Times is covering the story this week, pointing out the debate that’s heated over onto the web, into an online petition, and more.
In blogs, letters, and editorials, experts and advocates have been busy dissecting the implications of this and scores of other proposed revisions, now available online, including new diagnoses that include “binge eating disorder,” “premenstrual dysphoric disorder” and “attenuated psychosis syndrome.” The clashes typically revolve around subtle distinctions that are often not readily apparent to those unfamiliar with the revision process.
If a person does not meet precise criteria, then the diagnosis does not apply and treatment is not covered, so the stakes are high.
Well, not really.
In the real world of clinicians, they use the DSM more as a rough guide to diagnosis, not an absolute, black-and-white scientific manual (researchers do more of that). Clinicians know the real world is a messy, complex place, and so a person who presents with all the signs of a disorder, but who may not meet the specific number of symptoms for its diagnosis, are unlikely to withhold the diagnosis (and therefore, treatment) from them.
In the real world, clinicians already apply the DSM criteria in any way they see fit, by and large. And, I’d argue, there is a large swath of professionals — family physicians and primary care doctors — who may not even be familiar enough with the specific criteria for every disorder in order to diagnose them reliably right now.
But should we try and short-circuit our normal healing process by introducing anti-depressants or other treatments? How would such mood-elevating medications help us better understand and put into perspective another human being’s life?
Dr. Ron Pies had a few words to say on this topic more than 2 years ago, pointing out that sometimes grief can indeed turn into depression:
I recently had an essay published in the New York Times (9/16/08), in which I argued that the line between profound grief and clinical depression is sometimes very faint. I also argued against a popular thesis that says, in effect, “If we can identify a very recent loss that explains the person’s depressive symptoms — even if they are very severe — it’s not really depression. It’s just normal sadness.” […]
There are, of course, no “bright lines” that demarcate normal grief; complicated or “corrosive” grief; and major depression. And, as I argued in my New York Times piece, a recent loss does not “immunize” the grieving person against developing a major depression. Sometimes, it may be in the patient’s best interest if the physician initially “over-calls” the problem, hypothesizing that someone like Jim or Pete is entering the early stages of a major depression, rather than experiencing “productive grief.” This at least allows the person to receive professional help. The clinician can always revise the diagnosis and “pull back” on treatment, if the patient begins to recover rapidly. […]
But in cases where major depressive symptoms are present — even if they appear to be “explained” by a recent loss — some form of professional treatment is usually necessary.
You can read his full entry about the potential of grief turning into depression here. His point is well-taken — sometimes grief can indeed turn into depression.
More recently, Dr. Pies helped to clarify how this might fit into the DSM-5 specifically:
Since they are distinct conditions, grief and major depression can occur together, and there is clinical evidence that concurrent depression may delay or impair the resolution of grief. Contrary to widespread claims in the media, the DSM-5 framers do not want to limit “normal grief” to a two-week period — which would be foolish, indeed. […]
What are the implications of all this for the DSM-5? I believe that symptom check lists alone provide only a narrow window into the patient’s inner world. The DSM-5 should provide clinicians with a richer picture of how grief and bereavement differ from major depression — not just from the observer’s perspective, but from that of the grieving or depressed person. Otherwise, clinicians will continue to have difficulty distinguishing depression from what Thomas a Kempis called, “the proper sorrows of the soul.”
I’d encourage checking out his entire essay, The Two Worlds of Grief and Depression. (And, for the record, you should also read Dr. Pies’ latest entry on the DSM-5, Why Psychiatry Needs to Scrap the DSM System: An Immodest Proposal).
As for me, I remain somewhere in the middle.
I still remain largely unconvinced depression should be regularly or routinely diagnosed during the grief process. And I’m not sure anyone is arguing for that. But the current DSM doesn’t even make that an option, since it only offers an un-reimbursable “V-code” diagnosis for bereavement. If you have grief and depression co-occurring, today the DSM acts as though you don’t exist.
Critics of the proposed DSM-5 changes would like that situation to continue, apparently, putting their heads in the sand about the messy realities of the world — that depression can and indeed does co-occur with grief. Therefore I believe that ultimately the proposed changes to the DSM-5 in this matter are reflective of the reality of patients’ worlds.
Read the full article: Depression’s Criteria May Be Changed to Include Grieving
Read my previous entry on the DSM-5: Some of the Empty Arguments Against the DSM-5