No one wants to be sad. This can generally be agreed on. However, as it becomes more and more common for anti-depressants and anti-anxiety medications to be prescribed, the question becomes what is a socially acceptable level of sadness for a well-functioning member of society to experience? There remains a blurry, but important line between what is considered ‘normal’ grieving and what is classified as a mental disorder or depression. NPR’s Alix Spiegal recently explored a shift in this line due to changes in the criteria used by the American Psychiatric Association to diagnose depression.
Traditionally, the manual has steered doctors away from diagnosing major depression in people who have just lost a loved one in what’s called “bereavement exclusion.” The idea was that feelings of intense pain were normal, so they shouldn’t be labeled as a mental disorder.
But the new DSM changes this. Buried in the pages is a small but potentially potent alteration that has implications not only for people like Theresa, but ultimately for the way that we think about and understand the emotion of pain.
The DSM committee removed the bereavement exclusion — a small, almost footnote at the bottom of the section that describes the symptoms of major depression — from the manual.
Dr. Kenneth Kendler, a member of the committee behind the change, explains that grief and depression share the same symptoms – lack of sleep, loss of appetite, loss of energy. The key distinction between grief and depression is the amount of time the person experiences the symptoms.
In fact, in the new manual, if symptoms like these persist for more than two weeks, the bereaved person will be considered to have a mental disorder: major depression. And treatment, either therapy or medication, is recommended.
While Kendler believes that this change will only affect a small number, and for the better, Holly Prigerson a research at Harvard University believes otherwise.
“What we found,” Prigerson says, “is that when you follow people — for example, between zero and six months post-loss — their depression symptom levels actually increase over time and peak at about six months post-loss.”
Because grief and depression look so much alike, Prigerson says, she worries that people who are suffering from normal grief will be told that they are sick when they are not, and encouraged to treat their symptoms when they don’t need to.
That is potentially a problem, Prigerson says, because we don’t know whether the pain of normal grief actually helps people to process their loss.
Other experts expand Prigerson’s argument by voicing concern that society is continuing down a path to having an over-diagnosed and over-medicated population where to be sad is to be sick.
Dr. Allen Frances, the famous psychiatrist and a former editor of the DSM, says that more and more, psychiatry is medicalizing our experiences. That is, it is turning emotions that are perfectly normal into something pathological.
“Over the course of time, we’ve become looser in applying the term ‘mental disorder’ to the expectable aches and pains and sufferings of everyday life,” Frances says. “And always, we think about a medication treatment for each and every problem.”
From Frances’ perspective, if you can’t feel intense emotional pain in the wake of the death of your child without it being categorized as a mental disorder, then when in the course of human experience are you allowed to feel intense emotional pain for more than two weeks?
Comments 4
Richard H. — August 12, 2010
I wonder to what extent are these changes reflective of one of the pressures continuing us down the path of medicalization, namely, the considerations of the insurance industry? It's easy to see how reimbursement practices influence the decision to medicate versus traditional "talk" therapies, but harder to see the mechanism by which this would have influenced the DSM.
Arturo — August 13, 2010
In their book the "The Loss of Sadness" Allan Horwitz and Jeremy Wakefield argue that the DSM-IV represented a fundamental shift in how depression, but also mental health more generally, became classified. Essentially this edition of the DSM moved away from the previous subjective psychoanalytic descriptions of conditions, to a more "objective" purely symptom-based system for understanding mental health in the 1980s. That is, the objective science of checking off symptoms (noting if somebody is sad, for how long and so forth) became more important than understanding the subjective reasons and situational circumstances to why someone would have such emotions. In doing so Horwitz & Wakefield argue that psychiatry de-contextualized the diagnosis of depression; it mattered less why somebody was depressed or if they had a reason for being so The only exception where context still mattered in a diagnosis was the situation of bereveament--but as suggested above even this is being now questioned in the new drafts of the DSM-V.
H&W argue that the symptom-based understanding of depression has not only lead to the over-classification of pathological emotions the last 30 years, but this entire orientation has found a receptive audience in the broader society. HMOs and insurance companies not only prefer this more scientific standard for classifying billable conditions, but so do researchers who now have objective instruments to measure mental health. Patient advocacy groups and big pharma also approve of these developments because the research on symptoms bolster claims of legitmacy for such conditions and their treatments. In short, it's win-win dynamic for all groups involved. These can be seen as clearly positive developments to a certain degree, but as H&W argue the fundamental issue of whether feeling sad makes sense in certain situations, or if it may even be beneficial in some regard, gets obscured.
We've had two recent guests in our Office Hours podcast, that touched upon some of these issues:
Peter Conrad & the Medicalization of Everything
http://thesocietypages.org/officehours/2010/08/02/peter-conrad-on-the-medicalization-of-everything/
Allan Horwtiz and the Loss of Saddness
http://thesocietypages.org/officehours/2010/01/19/depression-culture-and-genetics/
shorelines — August 13, 2010
I read through the comments to the original story at NPR.org and I found one very interesting. I'll apologize up front for not having a link - I don't have the time to look for one particular comment out of over a hundred.
At any rate, a psychiatrist who agreed with the change made a comment arguing that it was motivated by the desire to avoid withholding treatment from those suffering only because the suffering was caused by grief. In other words, grief is no longer a reason to ignore a bereaved person's depression.
As a bereaved mother (I gave birth to a full-term stillborn son nearly two years ago) I have to say I think it is unlikely I would have been able to manage my grief without psychiatric help. Yes every emotion I felt in the face of such a shocking and traumatic loss was completely "normal" - and still it was much more than I could have managed without professional help. Help for me did not include medication, but it may be appropriate for other bereaved individuals.
Many who commented on the NPR story were angered that the psychiatric community seemed to be putting a two week time limit on "normal" grief after which it was considered pathological. In an ideal world the grieving could reside in the comfort and patience of their friends and family and wouldn't be expected to be "over it" until they actually were. Grief is a very lonely business in our culture, and so second best might be a world where those who need and want professional help dealing with their grief can get it without too much hassle form their insurance companies. But as it is, since we emphasize treating sickness and not nurturing health, if a diagnosis of sickness is the only way those struggling with normal grief can get help - I say, so be it.