The editors of the forthcoming fifth edition of the Diagnostic and Statistical Manual — psychiatry’s diagnostic handbook — are having a hard time. They’ve been attacked by autism advocacy groups for proposing to eliminate the Asperger’s diagnosis. They’ve been slammed for adding a diagnosis, or “prediagnosis,” for people determined to be “at high risk” of developing schizophrenia. And, now, they’re being pummeled for introducing a provision to diagnose grief as depression.
It has not gone unnoticed that the illnesses for which proposed definitions have been expanded are mainly those that are treatable by drugs — antipsychotics or antidepressants, for which manufacturers seek increased marketing opportunities — while the contractions tend to be in conditions for which no specific medication is available.
Indeed, the suggestion to label normal grief as depression would allow, for example, a bereaved widow to “treat” the sadness over the loss of her husband with Prozac — a condition that previously would have been remedied with time and family support. Meanwhile, other diagnoses that the DSM-5‘s editors have rejected — including developmental trauma disorder for children whose mental problems can be best explained by early negative experiences, such as being shuttled between multiple foster homes — often share the quality of not being easily amenable to pharmacological solutions.
This week, the editors of the prestigious journal The Lancet weighed in strongly on the mourning-as-mental-illness debate. The authors write:
Medicalising grief, so that treatment is legitimised routinely with antidepressants, for example, is not only dangerously simplistic, but also flawed. The evidence base for treating recently bereaved people with standard antidepressant regimens is absent. In many people, grief may be a necessary response to bereavement that should not be suppressed or eliminated.
The journal cites psychiatrist Kay Redfield Jamison, who suffers from bipolar disorder. She noted in her memoir about mourning her husband that she sees “a sanity to grief,” unlike her experience of the shifts in mood unlinked to external events that occur in bipolar disorder.
In a separate column in The Lancet, Dr. Arthur Kleinman, a professor of psychiatry at Harvard Medical School who lost his wife to Alzheimer’s, notes:
Professor David J. Kupfer, who chairs the DSM-5 Task Force making the revisions, is reported to have told The New York Times that making grief into a disease would allow psychiatrists to treat people who were suffering so that they would get the treatment they need for being depressed. And that’s the rub really. Is grief something that we can or should no longer tolerate? Is this existential source of suffering like any dental or back pain unwanted and unneeded?
To me — as someone who has suffered both depression independent of life experience and grief over the loss of my father — these are the right questions to ask. I self-medicated my depression with heroin and cocaine and became addicted, so I have also learned how to distinguish between the pathological desire to escape ordinary experience and the necessary treatment of excessive emotional pain.
The critical distinction between useful and needless suffering comes down to its meaning and effects. Losing a beloved parent matters; it would feel wrong not to hurt over it. But being deeply wounded over a minor perceived social slight, or being unable to work because you’re constantly tormented by self-hatred makes far less sense. The difference between illness and grief is proportionality and context — and in the context of a loved one’s death, grief should be rightly given precedence.
What strikes me as most absurd about defining mourning as depression is the argument that it’s necessary to allow medication to be prescribed to the bereaved. There’s no evidence that people who want antidepressants — including those who are in mourning — are routinely denied for lack of cause. Indeed, doctors are currently free to prescribe drugs “off label” as they wish in just these types of cases. There aren’t masses of prescription-seeking mourners in the streets demanding change.
Of course, it makes sense for bereaved people who also suffer chronic depression to be able to get help adjusting their medications so that grief doesn’t push them back into unremitting illness. But again, there’s nothing stopping doctors from doing this now and such people are already diagnosed with depression.
The proposed changes to the DSM-5 risk making psychiatry into a caricature by medicalizing everyday experience. They add to the stigma and public distrust of valid mental illnesses like depression by eliding it with normal mourning. Depression is not ordinary sadness, and neither is grief. The latter is a proportionate response to emotional catastrophe, which ultimately ennobles us; the former is an emotional catastrophe removed from its source, which simply corrodes.
By failing to make this fundamental distinction, psychiatrists risk making depressed people look like hedonists seeking to avoid normal life struggles, and mourners seem to be people who are improperly overvaluing what is in fact the most valuable experience of all, deep human connection. If we want to be mentally healthy, we need to be clear about these differences. Consequently, if psychiatrists really want to help their patients, they need to stand up to the DSM-5 editors and pharmaceutical companies to ensure that mental illnesses and normal extreme experiences are defined appropriately.