Grief: When is Sorrow an Illness?

When would you call sorrow a mental illness? By now nearly everyone has heard of the proposed change to the Diagnostic and Statistical Manual of Mental Disorder 5 (DSM-5) which would allow medical and mental health care providers to treat grief after the death of a loved one the same as major depression, in some cases with antidepressant. I posted about this last summer, pointing out that there is hardly a need for a change in the DSM, in my opinion, because the current diagnostic criteria for Major Depressive Disorder allows for a clinician’s judgment in discerning whether the vegetative and psychological signs and symptoms point to or away from normal bereavement.

Now, an editorial in the Lancet criticizes the American Psychiatric Association (APA) for proposing the change in diagnostic criteria for major depression, and would make it possible to diagnose it two weeks following the death of a loved one. According to the author, who did not sign the editorial:

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. Putting a timeframe on grief is inappropriate—DSM-5 and ICD-11 please take note. Occasionally, prolonged grief disorder or depression develops, which may need treatment, but most people who experience the death of someone they love do not need treatment by a psychiatrist or indeed by any doctor. For those who are grieving, doctors would do better to offer time, compassion, remembrance, and empathy, than pills.

Oops. Did I just say “normal bereavement”, thereby exposing a bit of bias? The reason I say that is because of a recently published CNN article by Dr. Charles Raison, CNNs mental health expert and associate professor of psychiatry at the University Arizona in Tucson (http://www.cnn.com/2012/02/16/health/raison-grief-depression/index.html?iref=allsearch), a psychiatrist who wonders if it makes any difference whether we diagnose major depression as a result of grief over the death of a spouse, for example, or an interpersonal crisis, such as a separation or divorce–which may have occurred several years in the past. We seem to be less reluctant to do so in the latter instance than in the former. And to Dr. Raison, it’s not clear why unless it’s the time course. He has a point when he remarks:

In fact, many years of research has failed to find anything magical that differentiates bereavement from depression.

He goes on to say that when we feel sad for whatever reason, we tend to develop other vegetative signs we usually use as indicators of major depression and that’s because, as he says, “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.”

Dr. Raison has been studying the mind-body connection for many years and has just recently moved from Emory to the University of Arizona where he brings his considerable experience and creativity in the study of how inflammation influences the development of depression in response to illness and stress. I’ve posted about his work before and so his perspective on grief is consistent with his scientific research focus (see short link http://wp.me/p1glcu-15i).

I think it’s interesting that so many of us think about grief in such opposite ways. On the one hand we think of sorrow as being a part of living, something inseparable from and even defining the human condition. We’re quick to point out that our society (at least in America; I can’t speak for the U.K.) has become accustomed to believing we’re not supposed to suffer, at least for very long, especially now that we have psychotropic drugs we can use to dampen (relieve) our emotional pain.

On the other hand, those who are suffering and, for whatever reason (genetic heritage or other vulnerabilities that may be biologically based), don’t have the resilience to counter sorrow may spiral into depressions that don’t lead to wisdom, only to more pain.

I doubt there’s a right or wrong answer to this dilemma. I think it’s important to be open to the suffering of our patients, whatever the reason, and be as open-minded as we can to the ways in which we can help them move forward.

The, L. (2012). “Living with grief.” The Lancet 379(9816): 589. doi:10.1016/S0140-6736(12)60248-7 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2960248-7/fulltext).