The grief illness debate continues

The loss of a loved one can trigger deep emotional turmoil, but is the grief that follows a normal part of being human or is it a form of mental illness in need of diagnosis and treatment?

That's the gist of a major debate now unfolding in the world of psychiatry, as the American Psychiatric Association (APA) prepares to issue the fifth edition of its seminal reference guide to mental disease, the Diagnostic and Statistical Manual of Mental Disorders (DSM).

The issue: for the first time, the manual - a touchstone for mental health professionals across the United States -- may not exclude the concept of "bereavement" from the constellation of behaviors and experiences that it deems worthy of consideration when clinicians set out to diagnose a major depressive disorder.

What does this mean? That feelings or outbursts accompanying the passing of a family member or close friend - such as crying, insomnia, fatigue, confusion and profound sadness - may now be viewed as a treatable illness rather than as a normal reaction to life's most shattering moments.

Not everyone agrees

"To me, grief is a normal condition, not to be tagged with a diagnostic code and to be treated," stressed Dr T. Byram Karasu, chairman of psychiatry and behavioral sciences at Albert Einstein College of Medicine and psychiatrist-in-chief at Montefiore Medical Center in New York City. "Everyone loses someone in their lives at some point. So, this would be classifying everyone at some point. No one would be immune to this."

"And that does not make sense, because grief is a normal and very healthy behaviour," said Karasu, who also chairs the APA's National Task Force on the treatment of depression. "One has to feel joy as well as pain and depression, otherwise life is not worth living. And one should not interrupt the grieving by medication or psychotherapy. You have to feel the loss, and only by feeling the loss and recovering from it will the person become a better person. Interrupted grief will remain unfinished business."

Karasu's stance is in line with those expressed by the editorial board of the British medical journal The Lancet, which lays out its opposition to the new clinical approach in a recent issue.

"Grief is not an illness," the journal's editors argue, noting that a diagnostic change in the APA's forthcoming manual would empower clinicians to interpret any post-loss despair that endures beyond a two-week window as a troubling sign of sickness rather than a standard sign of coping.

Medicalising grief

The Lancet team suggests that, instead, an intense but normal bout of grief can last six months to a year, depending on the very individualised nature of the particular relationship that has been severed by death.

"Medicalising grief, so that treatment is legitimised routinely with antidepressants, for example, is not only dangerously simplistic, but also flawed," the authors noted.

They acknowledged, however, that sometimes grief can morph into something much more complicated, longer lasting and "pathological." In such instances, true clinical depression may ensue along the lines of a so-called "prolonged grief disorder," a potentially new designation now under consideration by the World Health Organisation. And such patients, the board agreed, might stand to benefit from some form of mental health intervention.

The concern over exactly when normal grief becomes a condition that perhaps requires treatment is what's driving the notion of inclusion in the DSM, said University of California, San Diego, psychiatry professor Dr Sidney Zisook.

"It is well recognised that the death of a loved one, just like any other serious stressor, [such as the] loss of a job, diagnosis of a fatal illness, divorce can trigger a clinical depression," he said. "The ensuing depressive syndromes are no less severe or debilitating when brought on by bereavement as they are after any other life event or, indeed, when the depression seems to occur out of the blue."

"Acknowledging that bereavement can be a severe stressor that may trigger a clinical depression in a vulnerable person does not medicalise or pathologise grief," he suggested. "Rather, it prevents clinical depression from being overlooked or ignored, and facilitates the possibility of appropriate treatment."

"This acknowledgment," Zisook cautioned, "does not mean that we think acute grief should end in days, weeks or even months. For some, it may last for years, whether or not there is also a clinical depression. But, acknowledging that clinical depression may also be present in some bereaved individuals may go a long way towards helping those individuals get on with their lives."

Consistency

For University of Michigan Medical School psychiatry professor Dr  Randolph M. Nesse, the debate boils down to a tug-of-war between basic common sense on the one hand and science's search for diagnostic consistency on the other.

"Everyone knows that grief is something that happens to everybody," he noted. "And just because an emotion feels bad doesn't mean it's wrong or unhealthy. Most often it's a common-sense response to a real problem."

"So, my take is that it would be senseless to eliminate the grief exclusion [from the DSM]," said Nesse, who is also a professor of psychology at UM's College of Literature, Science and the Arts. "But, because it can be so damn hard to figure out when an emotion is normal or not normal without really knowing what is going on in a person's life, there are undeniable advantages to having a neat, clean, simple check-box kind of classification system for diagnosing depression. It makes it easier. So, you include grief as a box to tick, whether or not there is a real problem to be diagnosed."

"But that is what is so troubling," he added. "Because when someone gets a diagnosis of depression it then encourages giving that person treatment. And the getting of that treatment then pushes the person being treated into believing they do indeed have a problem that needs treatment to begin with. And that can be very unhelpful in many, many cases in which grief is really a normal and healthy response to a life event."

(HealthDay News, February 2012)

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