Last week some commotion arose over how grief – bereavement, mourning, feelings of loss – is treated in the concept text of the DSM-V. This is going to be the successor to the DSM-IV, the formal American Diagnostic and Statistical Manual of Mental Disorders. The new version 5 will be published in its final form by APA (the American Psychiatric Association) next year.
The DSM is used by many professionals (not just in the US) as the defining, authoritative diagnostic handbook. Version 5 is eagerly awaited because the last official version dates from 2000, and is considered outdated in some respects.
Many critical commentaries cropped up because last week it became clear that the new DSM concept text, unlike the old one, no longer makes a clear distinction between severe grief and depression (major depressive disorder).
The result of this omission is that in a case of bereavement after the death or departure of a loved one, if you for longer than a couple of weeks continue to suffer from feelings of deep sadness, loss, sleeplessness, crying, inability to concentrate, tiredness, and no appetite, this natural mourning process could be diagnosed as depression.
Worse, this mourning process might on the basis of such a diagnosis be treated with antidepressants in order to suppress the above-mentioned symptoms, instead of letting it run its natural course.
A natural process of coping with loss and grief usually runs through several phases, from initial shock and denial to eventual acceptance. Such a process as a whole can often take over a year but in the end, for most of us it will be healing: you may even emerge from it as a stronger, more stable person than you were before.
Even though during some phases the symptoms of such a mourning process may look very much like the symptoms of depression, it would be plainly unwise to immediately start treating it medically in the same way as depression. This would in fact mean disturbing and preventing something that works as a natural healing process.
This criticism on the new DSM approach was expressed very emphatically last week in a brief editorial Living with Grief in the prominent American medical journal The Lancet. The article strongly opposes the notion that grief could (or should) be classified as a form of illness. Of course sometimes depression can develop from too-prolonged grief, but this is not the usual case.
A few quotes from The Lancet:
“Medicalising grief, so that treatment is legitimised routinely with antidepressants, for example, 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.”
“Bereavement is associated with adverse health outcomes, both physical and mental, but interventions are best targeted at those at highest risk of developing a disorder or those who develop complicated grief or depression, rather than for all.”
“Grief is not an illness; it is more usefully thought of as part of being human and a normal response to death of a loved one.”
“For those who are grieving, doctors would do better to offer time, compassion, remembrance, and empathy, than pills.”
Because I fully agree, I have nothing to add here. Except that I hope that all these critical reactions will succeed in putting a halt to the unfortunate, unwarranted, and counterproductive medicalizing of normal emotional reactions.
Time for a different note. How would grief sound if it were music? Here is one of many efforts to catch it: “Grief” from the 1998 album Mesh & Lace by the group Modern English. A near-endless instrumental, but with song lines emerging at the end.
(if the player does not work, install Flash)
• tip: If you can clearly see an obvious primary reason why you feel intensely depressed, then ask yourself if your depression isn’t just grief.
In that case, try to understand that while a road of depression may run in circles, the tortuous road of grief will in the end nearly always get you somewhere.