- Until now, bereavement has always been excluded in the diagnosis of depression
- New guidelines might allow depression to be diagnosed after two weeks of grieving
- Dr. Charles Raison: No one has found anything magical that differentiates depression, grief
I am starting to think that there are no answers to the issues most worth writing about, at least in psychiatry.
Consider the following scenario: A woman who has been mostly happy in her marriage for 30 years comes home to find her husband dead on the floor, the victim of a heart attack.
At first, she is numb with shock. Slowly, as the days pass, she becomes more and more upset. She cries at any mention of her husband. She can't sleep. She can't eat. Nothing seems worth doing, and even if it was, she wouldn't be able to concentrate enough to get it done.
Sometimes she wishes she could die to be with her husband. Fifteen days after her husband's death, she goes to a doctor, who diagnoses her with major depression and puts her on an antidepressant.
If this scenario bothers you, it is likely because you feel the doctor has created an illness out of what most would consider normal grieving -- that he has trivialized the woman's loss by giving her pills to make it go away. If this is your reaction, you are not alone.
An editorial published Wednesday in the prestigious medical journal The Lancet takes the American Psychiatric Association to task for changes proposed in the next edition of the Diagnostic and Statistical Manual, which is the guiding document of psychiatry in the United States.
Until now, bereavement has always been excluded in the diagnosis of major depression. Not anymore. The current draft of the fifth version, known as DSM-V, will allow major depression to be diagnosed two weeks after the death of a loved one.
Major depression is a serious illness that profoundly impairs function, disrupts relationships and is a significant cause for early death. So it would follow that anyone who is upset most of the day, nearly every day, for at least two weeks after the death of a loved one is sick and needs treatment.
Yet the editors of The Lancet write: "Medicalizing grief, so that treatment is legitimized routinely with antidepressants, is not only dangerously simplistic, but also flawed. ... Building a life without the loved person who died cannot be expected to be quick, easy or straightforward. Life cannot, nor should not, continue as normal. ... Grief is not an illness; it is more usefully thought of as a part of being human and a normal response to death of a loved one. Putting a time frame on grief is inappropriate -- DSM-V ... please take note."
Hard not to agree. But consider the following scenario:
A woman who has been mostly happy in her marriage for 30 years comes home to find her husband having sex in their bed with her best friend. The husband tells his wife that he is terribly sorry, but he is in love with her best friend and will be leaving her.
At first, the wife is numb with shock. Slowly, as the days pass, she becomes more and more upset. She cries at any mention of her husband. She can't sleep. She can't eat. Nothing seems worth doing, and even if it was, she wouldn't be able to concentrate enough to get it done. Sometimes she wishes she was dead. Fifteen days after catching her husband in his indiscretion, she goes to a doctor who diagnoses her with major depression and puts her on an antidepressant.
Whereas the bereaved wife only gets depression status in the new DSM, the wife in this scenario would have qualified for a diagnosis of major depression for more than 30 years.
Doesn't this seem inconsistent at best, and perhaps disingenuous at worst? Is there really something magical about the loss of death that should give it a privileged status compared with other horrible losses in life, all of which are perfectly acceptable gateways into a diagnosis of major depression? Do we really believe that although the women in the two scenarios I've described experience exactly the same symptoms for the same length of time, the biological causes underlying these symptoms are somehow different just because one woman's loss involved death and the other woman's loss involved betrayal?
In fact, many years of research has failed to find anything magical that differentiates bereavement from depression.
Yes, there are studies showing that bereavement has slight differences in symptoms when compared with other types of depression. But there is also powerful data showing that all sorts of life stressors produce specific symptom patterns within depression, so this is nothing unique to bereavement.
Yes, most people who are bereaved eventually recover, but so do most people with depression, regardless of the inciting incident, or lack of one.
So that's the rub, and the rationale for removing bereavement as an exclusion from the next version of the DSM. And yet ... and yet, it still doesn't sit right. Should logic really so thoroughly trounce sentiment and tradition?
I would like to modestly suggest that the reason this dilemma is interesting, and has no answer, is that it is essentially wrong-headed, at least in light of what science is revealing about human responses to adversity.
We all tend to feel good when things go our way; we feel we are generally winning in the game of life. People who perceive themselves in this way are happier, healthier and live longer than their more pessimistic compatriots.
On the other hand, we all tend to feel anxious and depressed when we lose things and people of value to us, or when we lose in competitions or are shamed or lose status. Feelings of anxiety and depression can't last very long in humans without other symptoms following in their wake. This is for the simple reason that the mind is connected to the brain (or created by the brain), and the brain is connected to the body.
All over the world, people who are anxious and depressed also develop problems with sleep, appetite, concentration and energy. They feel badly about themselves and begin to feel like failures. When it gets intense enough, they want to die to escape their misery. This pattern of emotions and physical changes appears to be hardwired in humans, with some people being very vulnerable to this response and others being fairly resilient.
Sometimes the arising of these emotions and symptoms prods a person to make changes in his or her life for the better, and the experience is rightly seen as an essential component of growth and spiritual development. Sometimes these emotions and symptoms lead a person down into years of despair and misery, into a realm of diminished accomplishments, love and purpose.
What a pity that we as clinicians don't have crystal balls to accurately predict which path any given person will follow.
We can't look to the cause of the symptoms for clues, because that doesn't help. In fact, the only clue that even remotely approaches "crystal ball" status is how long the symptoms have lasted. The longer a person is depressed, or bereaved, the longer he or she is likely to remain in that state and the greater the long-term damage is likely to be.
So if you ask me how long someone should be allowed to remain in a state of bereavement before offering treatment aimed at resolving this condition, I have no answer.
Nor, to the best of my knowledge, does anyone else.
As I said at the beginning, there are no answers to the issues most worth writing about, at least in psychiatry.