Is Grief a Mental Illness?
Is grief a mental illness? Yes, according to proposed revisions to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), if the symptoms continue beyond a two-week period. No, you didn't misread it, all that crushing sadness, crying, lack of appetite and sleeplessness that follows the loss of a loved one could soon be diagnosed as depression, rather than (as is currently the case) normal grief. Needless to say the proposals have been met with a virtual tsunami of criticism.
The American Psychiatric Association has a small panel of experts currently working on the DSM revisions. Until now grieving has been given a two month window, the so-called "bereavement exclusion", before mourning might be classed as major depression. Even so, anyone who has ever lost a loved one, and I include myself in the mix, knows that grieving is a gradual and long-lasting process. Most people will say their grief intensity lasts at least a year, the first anniversary being a critical time. Thereafter, if we are fortunate, the level of intensity may subside just a little.
In a damning editorial, The Lancet describes the medicalization of grief as, ‘not only dangerously simplistic, but also flawed. The evidence base for treating recently bereaved people with standard antidepressant regimens is absent.' There already exists an acknowledgement that in some cases grief can tip over into a more pathological state, currently referred to as complicated grief. In such circumstances treatment is both recommended and available.
But part of the danger, it appears, is the way the DSM is taken so literally by some of its users. Writing in the New York Times, Gary Greenberg picks up this very point. Greenburg points out that psychiatrists know the disorders listed in the DSM are really no more than constructs. They provide some guidance as to how symptoms cluster, but the DSM itself is neither objective nor scientific, nor as Greenberg indicates do ‘the few markers, the genes and the neural networks that have been implicated in mental disorders,map well onto the DSM's categories.'
That aside we have to ask how useful such revisions might be for the average busy family doctor, perhaps with little knowledge of the supposed subtle differences between normal grief and clinical depression? The danger, of course, is they err on the side of caution and prescribe antidepressants.
Allen J. Frances, M.D., was chair of the DSM-IV Task Force and is currently professor emeritus at Duke. He also opposes the proposals, describing them as both ‘silly and unnecessary'. But, of course, views vary between clinicians, as can be seen in Stephen Diamond's rebuttal.
The debate is long, ongoing and somewhat complex, but I think you may be interested in the aforementioned blogs and the comments they have variously generated. Feelings are running high - what do you think?
Living with grief. The Lancet, 379, 9816, page 59, 18 February 2012