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The medicalization of grief

We all deal with grief in different ways.

Is grief part of the normal human experience, or is it a "problem" in need of fixing?

When the fifth edition of the Diagnostic and Statistical Manual, the so-called Bible of mental health disorders, is published next year, it more than likely will contain major revisions in how some conditions - personality disorder, for instance - are defined and diagnosed.

Of all the revisions that are under review, few have been more intensely debated than the one that would add complicated grief to the list of major depressive disorders and that would allow depression to be diagnosed within two weeks of a loss.

Will it mean that millions of bereaved individuals will be labeled with a mental disorder simply because they're grieving? Many say this could be exactly what happens.

The discussion boiled over this month with a blog entry by Dr. Joanne Cacciatore, a researcher at Arizona State University and founder of a nonprofit group for grieving parents. The proposed revision - especially the two-week time frame - would have the effect of "further pathologizing the authentic human experience of sorrow," Dr. Cacciatore wrote. "So, a person may, at the discretion of a psychiatrist, social worker, or psychologist, be categorized as 'mentally ill' as soon as two weeks following the death of a loved one."

Bereavement isn't a state that can be healed with pills or therapy, she writes. "If we wish, as a society, to truly help those suffering in the aftermath of loss, then we must make the move toward collective compassionate and open hearts. Systems of 'care,' HMOs, hospitals, and evidence-based practice manuals will not help heal others."

There isn't always a clear line between grief and depression. Often they resemble each other, and at times they may overlap. But how much of this is normal and how much should be considered "disordered"?

In a statement issued in response to the uproar over the DSM-V's proposed handling of grief, Dr. Kenneth Kendler, a member of the work group on mood disorders, offers a perspective on where the dividing line might lie:

... The vast majority of individuals exposed to grief and to these other terrible misfortunes do not develop major depression. That does not mean, and here is the source of much confusion, that they do not grieve. They do. It does not mean that they do not feel terrible pain and loneliness. They do. Depression is a slippery word and we are so used to using it to mean "sad", "blue", "upset" or, in this specific case, "grieving." Major depression - the diagnostic term - is something quite different.

How much of this debate is rooted in a broader cultural aversion to grief, loss and suffering and a belief that it's somehow better for bereaved individuals to blunt their pain with medication or therapy? A mother who lost her firstborn son to stillbirth had this to say in response to Dr. Cacciatore's blog:

"there are some things in life we just need to FEEL with every nerve ending (physical and emotional), no matter how much it hurts. that's the only way to get through it, come to terms with it, and learn to live with it."

For some people, grief can indeed become so prolonged or intense that it interferes with their ability to function. These individuals may need help but it doesn't necessarily mean they're clinically depressed - or, more to the point, that they should be treated the same way as someone with depression, argue Dr. Allen Frances, a professor emeritus at Duke University who chaired the DSM-IV task force, and Dr. Holly Prigerson, a Harvard psychologist who specializes in grief.

Although it's possible for someone with prolonged grief to also have major depression, the two conditions aren't interchangeable, Dr. Prigerson explains. "In the context of bereavement, survivors are likely to experience symptoms of both depression and grief. But the characteristics that define an orange, or grief, are not the same as those that define an apple, or depression."

Dr. Frances concludes: "It is important to respect the legitimacy of all forms of grief, but also to provide a helping hand to those who need it."

What do readers think about the DSM-V proposal? Does it medicalize normal grief? Will it help bereaved individuals experiencing prolonged or severe grief?