GRIEF VS. DEPRESSION DEBATE CONTINUES AFTER DIAGNOSIS CRITERIA ALTERED

As I wrote in my last post regarding the recently released DSM-V revision eliminating the bereavement exclusion for depression, "this dialogue and debate will be ongoing." Hopefully, the discussion will be constructive and solution-oriented, and I'd like to contribute to it -- in that spirit -- whenever possible, so I am responding to the invitation of Donna Schuurman, Executive Director of the Dougy Center, to share "When Does a Broken Heart Become a Mental Disorder?" with readers of the Grief after Suicide blog.

The document, created only a week ago by an ad hoc group at a meeting of the International Work Group on Death, Dying and Bereavement, protests what Schuurman calls (in her comments to the American Association of Suicidology listserv, where she posted it) "the trend to pathologize grief" by outlining the three main points in the argument against eliminating the bereavement exclusion (namely, grief is not depression; antidepressants are already overprescribed; and most antidepressants are prescribed by primary care practitioners who, it is feared, will misprescribe them to bereaved people).

Below is an excerpt from my response to Donna on the AAS listserv, which summarizes both the argument in favor of the exclusion and my point of view about the matter, lists a couple of resources I have found to be helpful, and takes a run at framing the debate in the larger context of what I allude to as problems related to the "DSM 'industry'":

As I've followed the debate on this topic over the past two years, I have gone back-and-forth myself between my concerns, on the one hand, about points such as those raised in the statement [from the ad hoc IWG group] and, on the other hand, the main concern raised by those in favor of eliminating the exclusion (which, in brief, is that eliminating the exclusion would enable more-effective treatment for a significant number of people who need and might truly benefit from treatment for depression that is co-occurring with their bereavement).

In my last post on the issue on the "Grief after Suicide" blog (titled "DSM V Change Requires Skilled Clinicians To Separate Grief From Depression" at bit.ly/griefvsdepression), I wrote:

"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 [Sidney] Zisook suggests, 'provide more training and consultation to the other treatment professionals who might see grieving patients.'"

Now that the exclusion is a fact, this issue of having "skilled clinicians [able] to separate grief from depression" seems to me to be the essential operational matter that must be addressed. But I know of no strategy in place or planned that is designed to improve upon those skills where improvement is most needed.

Your ad hoc work group's statement advises,

"Be wary of physicians or other medical professionals who rush to prescribe antidepressants to address your grief ... Don't be afraid to seek professional help, but if you do, ask about the person's training, qualifications, and experience with grief, loss, and bereavement."

That is certainly great advice, but are we left with only patients' case-by-case self-advocacy to counter-balance an obvious lack of training in the workforce? That basically describes the status quo, for by-and-large the traumatically bereaved -- often people who are relatively debilitated by grief, and in some cases people with actual psychiatric disorders related to their grief -- are commonly left to "figure it out themselves" when it comes to getting effective assistance and support.

I will leave it at that for now, but would refer anyone interested in this topic to the following:
* "Grief and Bereavement: What Psychiatrists Need to Know" at bit.ly/psychgrief (from a 2009 issue of "World Psychiatry"), in which Sidney Zisook and Katherine Shear delineate the differences -- clinically -- between grief and depression
* The 2011 seven-part series in Medscape Today at bit.ly/definedistinction, which covered both sides of the argument about the bereavement exclusion in as balanced and complete a fashion as I could find during the debate (Medscape Today requires registration, which is free, and which I recommend)

In closing, for those readers who might notice feeling uncertain from what I've written above regarding where I stand on the bereavement exclusion -- for or against it -- I must admit that I cannot say myself, for the "machinery" in which the debate has been "processed" is essentially broken, by which I mean that surely this is an example of how the DSM "industry" itself has fundamentally gone astray in its stewardship over mental health care.

/signed/ Franklin