Grief: Normal, Not A Mental Illness

Feb. 16, 2012— -- Grief following the death of a loved one isn't a mental illness that requires psychiatrists and antidepressants, according to editors of The Lancet, who oppose "medicalizing" an often-healing response to overwhelming loss.

Routinely legitimizing the treatment of grief with antidepressants "is not only dangerously simplistic, but also flawed," says the unsigned lead editorial appearing in Friday's edition of the influential international medical journal. "Grief is not an illness; it is more usefully thought of as part of being human and a normal response to the death of a loved one."

In rare cases, a bereaved person will develop prolonged grief or major depression that may merit medical treatment "or sometimes more effective psychological interventions such as guided mourning may be needed," they wrote. However, they suggested that for the majority of the bereaved, "doctors would do better to offer time, compassion, remembrance and empathy, than pills."

The editorial opposes the American Psychiatric Association's controversial proposal to re-categorize grief reactions as a mental illness in the upcoming edition of the Diagnostic and Statistical Manual of Mental Disorders, (DSM-5), due out in 2013. That book, often referred to as the Bible of psychiatry, defines mental health disorders and assigns them diagnostic codes which, among other things, drive health insurance reimbursements for treatment. Among other pending changes in the DSM-5 are the addition of premenstrual dysphoric disorder, and a revised definition of autism that some critics and parents fear could limit the number of youngsters receiving medical, social and school-based services for autism spectrum disorders.

The proposal opposed by The Lancet's editorial writers would eliminate the so-called "grief exclusion." For years this "exclusion" has said that someone who has experienced recent bereavement is ineligible for a diagnosis of major depression for a set period of time, according to a defense of the change written by Dr. Kenneth S. Kendler, a member of the DSM-5 Mood Disorder Working Group and posted on the DSM-5 website.

An earlier manual, the DSM-III, said a person could go through the grieving process for a year before a psychiatrist determined that persistent feelings such as sadness, disturbed sleep, loss of appetite, low energy and poor concentration constituted depression to be addressed with medications and psychotherapy.

More recently, the DSM-IV shrank that period to two months. The pending revision to the DSM-5 would shrink that period even further, allowing the psychiatrist to diagnose depression following two weeks of such symptoms.

In defending that shorter period, Kendler said it "provides the possibility but by no means the requirement that treatment be initiated," and suggested doctors have the option of so-called "watchful waiting." Good care involves "intervening only when both our clinical experience and good scientific evidence suggests that treatment is needed."

Dueling Views: Boon to Psychiatry vs. Benefit to the Bereaved

The two sides of the debate were laid out in an accompanying Perspectives piece by Dr. Arthur Kleinman, a Harvard psychiatrist, social anthropologist and global health expert.Critics of the change contend that with a looser standard, the APA would be creating more patients, and more demand for medications, thus making bereavement "a potential profit center for the business of psychiatry." Supporters of the change contend that bereaved people with disabling symptoms would benefit from the recognition and treatment, he said.

The central problem, as Kleinman sees it, is the lack of "conclusive scientific evidence to show what a normal length of bereavement is." Drawing from his anthropological studies, he said that "across the world, societies differ greatly in what they regard as normal grief: some do regard a year as a marker, and yet others sanction longer periods – even a lifetime."

Kleinman recounted his own experience of losing his wife of 46 years to Alzheimer's disease in March 2011, describing the agitation, fatigue, weight loss and other symptoms that set in. It took 6 months before his grief lessened. Nearly a year since he became a widower, he continues to experience "sadness at times and harbor the sense that part of me is gone forever."

"My grief, like that of millions of others, signaled the loss of something truly vital in my life," Kleinman wrote. "The pain was part of the remembering and maybe also the remaking. It punctuated the end of a time and a form of living, and marked the transition to a new time and a different way of living."

According to the editorial writers, "it is often not until 6 months, or the first anniversary of the death, that grieving can move into a less intense phase." Grieving also is individual, shaped by age, gender, religious beliefs and the strength of the relationship with the lost loved one, they said.