I very much appreciate Sidney Zisook's blog post at Scientific American, "Getting Past the Grief over Grief," in which he tells of discussions he had with a colleague who lost his son to suicide almost a year ago about the removal of the bereavement exclusion from the criteria for diagnosing depression in the recently approved DSM V .
Like many who have debated this issue for the past several years (for an overview of the debate about the bereavement exclusion and links to comprehensive background information, see this blog post), Zisook's colleague was worried that not keeping bereavement as an "exclusion" from a depression diagnosis indicated that, in Zisook's words, psychiatrists' "goal was to diagnose every grieving person with major depressive disorder." In his colleague's words,
"How dare they label me with depression, as though I should have been over my grief months ago? How dare they imply I should take medications to drown my sorrow?"Zisook's reply is a straightfoward summary of the argument that psychiatrists have no such goal in mind and, on the contrary, are not interested in indiscriminately labeling and medicating bereaved people. The change was made to the DSM, he says:
To make sure clinicians and patients understand that major depression can occur in someone who is bereaved, just as it can occur in someone who is going through a divorce, facing a sudden disability or terminal illness, or struggling with serious financial troubles. There are no known clinically meaningful differences in the severity, course or treatment response of major depressive episodes that occur after the death of a loved one compared to those occurring in any other context. According to the best research available, any very stressful life event can trigger a major depressive episode in a vulnerable person; [and] regardless of the context in which it occurs, prompt recognition and appropriate treatment can be life-promoting and even life-saving. (Emphasis added.)
This argument seems to me to be the most cogent -- and valid -- reason for changing the DSM, but like Zisook's colleague, I am concerned about how the change is applied in primary care settings, for most anti-depressants are prescribed by doctors who don't have the training psychiatrists have in differentiating between intense, sustained grief and depression, and I wonder if there are practical -- and ambitious -- plans to have psychiatrists, as Zisook suggests, "provide more training and consultation to the other treatment professionals who might see grieving patients."
In any event, this dialogue and debate will be ongoing, for as Greg Eghigian asserts in "The Medicalization of Grief: What We Can Learn From 19th-Century Nervousness":
No matter how we might define and assess it, the relationship between medicine, social values, and prevailing ideals for living is perhaps messier and more convoluted than it might seem at first glance.And in "Depression and the Limits of Psychiatry," Gary Gutting invites those working in the field of psychiatry to more purposefully include experts from other disciplines into their decision-making process, citing as examples "specialists in medical ethics" and those "from a new but rapidly developing field, philosophy of psychiatry." Gutting also makes a bid for the bereaved to be included in the dialogue in a meaningful way:
We should include those who have experienced severe bereavement, as well as relatives and friends who have lived with their pain. In particular, those who suffer (or have suffered) from bereavement offer an essential first-person perspective.The DSM V is the "bible" as far as diagnosing mental illness is concerned, but it does not ultimately dictate how mental health care is actually delivered. If health practitioners of every stripe take as their highest priorities compassion, wisdom, skill, and concern for serving each individual bereaved person's singular needs, then we have nothing to fear from the DSM.
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