The recently posted draft of DSM5 makes a seemingly small suggestion that would profoundly impact how grief is handled by psychiatry. It would allow the diagnosis of Major Depression even if the person is grieving immediately after the loss of a loved one. Many people now considered to be experiencing a variation of normal grief would instead get a mental disorder label. For example, take the case of a man whose spouse unexpectedly dies. For two weeks after the death, he feels sad, doesn't want to go to work, loses his appetite, has trouble sleeping and concentrating. Currently, this is normal grief. The DSM 5 suggestion would have this be major depression.
Undoubtedly, this would be helpful for some people who would receive much needed treatment earlier than would otherwise be the case. But for many others, an inaccurate and unnecessary psychiatric diagnosis could have many harmful effects. Medicalizing normal grief stigmatizes and reduces the normalcy and dignity of the pain, short circuits the expected existential processing of the loss, reduces reliance on the many well established cultural rituals for consoling grief, and would subject many people to unnecessary and potentially harmful medication treatment.
Grief is an inescapable part of the mammalian experience and a necessary correlate of our ability to attach so strongly to other people. Though grief is universal, there is no one right to grieve. Different cultures prescribe a wide variety of different behavioral and emotional reactions and rituals. Psychiatry needs to tread lightly and have compelling reasons before encroaching with its own rituals on such time honored and usually effective practices.
Within a given culture, normal individuals also vary enormously in the content, symptoms, duration, and impairment of their grief and in their ability to draw consolation and sustenance from others. There is no bright line separating those who are experiencing loss in their own necessary and particular way from those who will stay stuck in a depression unless they receive specialized psychiatric help.
The numbers on each side of the normal/mental disorder divide are probably very lopsided-most people who grieve do not have a mental disorder. Ever since the dawn of man, humans have had frequent occasions to grieve. Almost all of us come to terms with the loss and the altered conditions of a new life without the benefits of psychiatry-and do just fine on our own. The change in DSM5 would attempt to identify the very small percentage of people who have a complicated grief that goes beyond the average expectable in severity, symptom pattern, and duration - those who would not remit as part of the natural evolution of their grief. But when you use a big shovel to capture a small needle in the haystack, what you mostly get is hay. Any change in the way DSM5 defines grief may gather a very large proportion of false positives who would do better avoiding psychiatric help.
The rationale given by DSM5 for its radical proposal is brief, cryptic, and fails to provide anything like a risk/benefit analysis of potential effects. DSM5 states that there is no evidence that the depression triggered by the stress of losing a loved one is any different than depression triggered by other severe stressors (such as job loss or divorce)- thus claiming that there is no justification to withhold the diagnosis of major depression after a loss. This rationale places the burden of proof in the wrong direction. DSM5 should make so consequential a change only after a careful and considered evaluation proves with compelling evidence that it will do more good than harm.
Such evidence is simply not available. The research in this area is interesting but in very early development and we don't know many essential things. We have no idea how any proposed criteria set would work in the general population. What percentage of grieving individuals would get the diagnosis (especially once drug companies raise awareness of it)? Among the people who would be diagnosed, we don't know what percentage truly need psychiatric help, what percentage would do better without it.
Pies and Ziskind (in a recent commentary in Psychiatric Times) have gone far beyond the meager DSM5 rationale to present the strongest possible case for allowing the diagnosis of Major Depression in grief situations. They cite several lines of argument:
1)There is a clinical need- some individuals have severe, complicated grief that looks just like severe Major Depression and does not get better spontaneously. The longer that diagnosis and treatment are delayed, the greater their suffering, impairment, and risks (eg job loss, injured relationships, lowered treatment response, suicide).
2)The loss of a loved one is not essentially different from the many other serious stressors that abound in life.
3)It is impossible to predict the future misuse of the DSM5 system so we should make decisions based only on the best possible science.
4) The criteria for complicated grief could be tightened to reduce false positives.( They suggest two useful ways described below and I add two others).
5)Education can solve the problem of false positive diagnosis and the risk of providing medicine in milder cases when time, support, and/or psychotherapy would be more indicated.
The excellent proposal made by Pies/Ziskind to reduce false positives could be strengthened even further if two additional exclusions were added to the two(#'s 1and 2 below) that they suggested . The entire package differentiating grief from depression would require:
1)An extended duration of one month.
2)A particularly severe presentation that includes some combination of unreasonable guilt, worthlessness, hopelessness, self loathing, anhedonia, a focus on negative memories of the departed, alienation from others, and inability to be consoled.
3)To recognize the different cultural expressions, the diagnosis of depression would not be made if the person's grief is within cultural norms.
4)An exclusion could be added that would take into account the person's own past experience of grief and its previous outcomes. If the individual previously had severe grief symptoms, but recovered spontaneously (without going on to a major depression), this would suggest they are now grieving their own way and do not require diagnosis or treatment.
