Good Grief: The APA Plans to Give the Bereaved Two Weeks to Conclude Their Mourning

Britain's "Lancet" calls the proposal "dangerously simplistic and flawed."

Posted Feb 17, 2012

"Previous DSM editions have highlighted the need to consider, and usually exclude, bereavement before diagnosis of a major depressive disorder," the editors explain. "In the draft version of DSM-5, however, there is no such exclusion for bereavement, which means that feelings of deep sadness, loss, sleeplessness, crying, inability to concentrate, tiredness, and no appetite, which continue for more than 2 weeks after the death of a loved one, could be diagnosed as depression, rather than as a normal grief reaction."

Think about that for a moment. The APA is seriously proposing that anyone who can't conclude their grief and mourning within two weeks could be liable for a diagnosis. Most people suffering a bereavement would scarcely be able to arrange a wake within that time, much less come to terms with the scale of their loss. Yet such is the APA's astonishing presumption of efficient, on-schedule mourning that it is, in effect, giving everyone just two weeks to get over the loss of loved ones.

"It is often not until 6 months," the Lancet editors feel the need to point out, "or the first anniversary of the death, that grieving can move into a less intense phase. Grief is an individual response to bereavement, which is shaped by the strength of relationship with the person who has died, being male or female, religious belief, societal expectation, and cultural context, among other factors."

"The death of a loved one can lead to a profound, and long-lasting, grieving process," they add, "which is movingly described in an essay by [Harvard psychiatrist and medical anthropologist] Arthur Kleinman in this week's 'Art of Medicine' section. After his wife died, it took 6 months before Kleinman's feelings of grief became 'less acute' in his own words, and almost a year on, he feels 'sadness at times' and harbours 'the sense that a part of me is gone forever... I am still caring for our memories. Is there anything wrong (or pathological) with that?'"

Not in the least, to state the obvious. "Most people's experiences of grief would align with Kleinman's," the Lancet editors note, before criticizing the APA for assuming otherwise: "Medicalising grief, so that treatment is legitimised routinely with antidepressants ... is not only dangerously simplistic, but also flawed. The evidence base for treating recently bereaved people with standard antidepressant regimens is absent. In many people, grief may be a necessary response to bereavement that should not be suppressed or eliminated.... Building a life without the loved person who died cannot be expected to be quick, easy, or straightforward."

Unless you serve on an APA committee, of course.

Professor Kleinman's moving essay, "Culture, Bereavement, and Psychiatry," is, like the editorial, open-access and available here.

Elsewhere in this week's edition of The Lancet, Drs. Paolo Fusar-Poli (Institute of Psychiatry, King's College London) and Alison R Yung (Orygen Youth Health Research Centre, University of Melbourne) voice serious "concerns ... that the inclusion of" yet another DSM-5 proposal, Attenuated Psychosis Syndrome, "could result in patients with symptoms being labeled as having an illness and could lead them to seek treatment unnecessarily, or for others to seek treatment on their behalf. On balance," they write, "since the high-risk group is heterogeneous in presentation, clinical needs, and outcome, we believe that inclusion of attenuated psychosis syndrome as a new DSM diagnosis would be premature."

Fusar-Poli and Yung's contribution weighs the pros and cons of the proposal carefully, writing more diplomatically than even the editors of The Lancet, but there's no mistaking their "arguments against the inclusion of the high-risk category in DSM-5 ":

The main concerns relate to the potential high number of false-positive diagnoses of patients who are not actually at risk of psychotic disorder. Additionally, people meeting the criteria might be incorrectly thought of as being in the range of schizophrenic disorders. Most clinicians and general practitioners surveyed incorrectly regarded attenuated psychosis syndrome as a mental disorder related to psychosis and schizophrenia. Possible unintended negative consequences of such a diagnosis include stigma, discrimination, and unnecessary treatment. Some high-risk patients are given antipsychotics (which can have effects on the brain), even though these drugs are not recommended in treatment guidelines. Diagnostic creep might occur, which could result in lowering of the high-risk threshold and a subsequent reduction in risk of transition to a full-blown psychotic disorder.

Any one of these likely scenarios should of course deter the APA from formalizing either proposal in DSM-5. What are the odds that the APA will listen?