Psychiatry’s New Rules Threaten to Turn Grieving Into a Sickness
A controversial change to official psychiatric guidelines for depression has raised fears that grief over the death of loved ones will be classified as clinical depression, turning a basic part of what it means to be human into a recognized sickness.
The change, contained in new revisions to the DSM-5, a set of standards used to categorize mental illness, eliminates the so-called bereavement exclusion, which exempts grieving people from diagnoses of depression for two months unless their symptoms are self-destructively extreme. Under the new standards, depression can be more easily diagnosed just two weeks after a death.
“Virtually everyone who is grieving has milder symptoms of depression. What the bereavement exclusion did is separate the normal responses from the severe ones,” such as feelings of worthlessness or suicidal impulses, said psychiatrist Jerome Wakefield of New York University, who studies bereavement and depression.
“This goes over a line. If you can pathologize this kind of feeling, any kind of suffering can be a disorder. It’s a disagreement over the boundaries of normality,” Wakefield said. “What kind of world do you want to have? One where intense, negative feelings we don’t like are labeled as disorders, or a world where people grieve?”
Defenders of the bereavement exclusion’s removal, officially announced Dec. 1 by the American Psychiatric Association, say worries of pathologized grief are overblown. They argue that though not all grieving is depressive, grief-related depression isn’t fundamentally different from what’s considered normal depression. As a result, they say the exclusion makes it unnecessarily difficult for clinicians to deal with bereaved people who legitimately need help.
“I think a good clinician can separate the two,” said Jan Fawcett, a University of New Mexico psychiatrist and head of the DSM-5 working group that authored the change, of normal grief and clinical depression. “We feel that clinicians have been making this judgment all along.”
The DSM, or Diagnostic and Statistical Manual of Mental Disorders, represents American psychiatry’s official tool for deciding between mental disorders and normality. First drafted in 1952, it’s now known euphemistically as psychiatry’s Bible, used by doctors, insurance companies, the legal system, and most any social institution that deals formally with mental health.
The DSM has been revised four times since its original publication, with the latest changes developed over the last seven years and culminating in the recent approval. These have been perhaps the most controversial changes ever, partly because they’re the first made in the cacophonous media environment of the internet age, but also because of the changes themselves. New conditions include hoarding, severe pre-menstrual syndrome, binge eating, temper tantrums and everyday forgetting among the elderly. Critics say these represent a tendency in modern psychiatry to medicalize the normal range of human experience.
Far and away the most controversial change is eliminating the bereavement exclusion, which discouraged clinicians from diagnosing as depressed grieving people whose symptoms were actually part of a normal, necessary emotional process, though in other people they’d be considered formal grounds for depression.
In 1980′s DSM-3, the exclusion was set at a full year, a period reduced in the DSM-4 to two months. Many psychiatrists already considered that an insufficient time for grieving. When Fawcett’s working group asserted that depressive symptoms in bereaved people could be viewed like regular depression, qualifying as pathology if enough persisted for any two consecutive weeks, the outcry was immense.
Editorials opposing the decision appeared in prominent medical journals The Lancet and New England Journal of Medicine, as well as blogs like one written by grief counselor Joanne Cacciatore, who said the decision “seems hardly human at all” and called for a boycott of the DSM.
Critics argued that many symptoms of depression — sadness, loss of interest in once-pleasurable activities, weight loss or gain, sleep problems, fatigue — overlap so closely with the normal experience of grief, especially when a family member or close friend has died recently, that grieving people would inevitably and inappropriately be diagnosed with depression.
“I’ve seen thousands and thousands of patients, and I can’t tell the difference,” said psychiatrist Allen Frances, who chaired the DSM-4 revision process but has become an outspoken critic of DSM-5. “The idea that you can tell them apart is a fiction.”
In response to the criticisms, the DSM-5′s authors added a footnote instructing clinicians to take recent loss into account when evaluating mild depressive symptoms. To the critics, a footnote doesn’t provide the recognition of grief’s normality contained in the bereavement exclusion.
Many psychiatrists do, however, support the decision. They say distinguishing between grief-related depression and regular depression is illogical. “Defenders of the removal of the exclusion ask, ‘Why should people be denied the diagnosis if their stressor happens to be bereavement, whereas other sufferers whose stressor is job loss, for example, are not?’” said psychiatrist Richard McNally of Harvard University.
According to Daniel Carlat, a psychiatrist at Tufts University, bereavement sends some people into a depression from which they don’t easily recover. “There seems to be a sub-category of people who are not able to get themselves out of it, who feel worse than other people, whose lives are more profoundly affected than others,” he said. “Those are the ones we don’t want to miss.”
Whether those people are missed now is debatable. Fawcett said he doesn’t expect a significant increase in diagnoses of major depression. Instead, removing the exclusion will simply eliminate an unnecessary complication for clinicians who already make the diagnoses they need to.
But Frances anticipates a rise in depression diagnoses, as many are made not by mental professionals but by primary care doctors.
“The DSM is created by psychiatrists, but it’s not just for psychiatrists and mental health workers,” he said. “If I have trouble distinguishing between grief and depression, I certainly don’t trust primary care doctors seeing patients for seven minutes, who are influenced by drug salesmen, to do it.”
Frances cited as cautionary examples several dramatic diagnostic increases that followed revisions to the DSM-4. “For attention deficit disorder, we expected a 15 percent increase. It tripled. For autism, we expected a 3 or 4 percent increase. It was 20-fold. For adult bipolar, we expected a slight increase. It doubled,” he said. “One of the things I learned in DSM-4 is that once words are written, you lose control over them.”
Implicit in Frances’ concern is the possibility of antidepressants becoming front-line treatments for grief-related depression. While drugs aren’t necessarily the best option, the medical establishment favors their use, and some 80 percent of all antidepressant prescriptions are written by primary care doctors rather than psychiatrists.
“I think those concerns are legitimate,” McNally said. “People giving these medications are often primary care people. They often don’t have time to do full assessments. And there’s an issue with some insurance companies being reluctant to reimburse for treatments, such as cognitive behavioral therapies, unless a patient is taking medication — or, worse yet, unless they’re only taking medications. There are these institutional biases.”
Wakefield worries that treating grief with medication will have the unintended consequence of eliminating aspects of the experience that, though painful, are valuable.
“Does medicating yourself retrospectively edit what your relationship was? It’s possible,” Wakefield said. “If you change your emotional stance, you can to some degree re-edit your very memories. You see that in people with post-traumatic stress disorder. The evidence isn’t there yet for grief, but I’d imagine the same would hold true.”
Less speculatively, said Wakefield, an increase in unnecessary diagnoses could affect life insurance status, clinical trial participation, legal claims, and other practical matters in which mental health status is logistically relevant.
“There will be very few people who need this diagnosis that aren’t getting it now, and considerable risks to and costs to individuals and society as a whole,” Frances said.
But Fawcett, who stresses that the decision was based on the best available scientific data, isn’t backing down.
“Anyone is free to contest these decisions and publish data showing how wrong we were,” Fawcett wrote in an e-mail, noting that future DSM revisions will happen more frequently than before. “If, as planned, the DSM-5 becomes a living document, and the doubters bring forth evidence that we made wrong decisions … then DSM 5.1 may correct our mistakes.”