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Grief Differs From Depression: Our Mental Health Guidelines Should Clarify, Not Distort

By removing the "bereavement exclusion" from what had been considered the bible of the mental health world, the DSM's editors risk undermining bereavement as a universal, normal, if profoundly painful, experience.
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How do you face another day when half your life is no longer here? Do you give up and walk away with happiness to a distant place? Or do you leave the door of your heart ajar so that healing will enter and life reborn?

These words were written by a grieving husband sharing his loss, pain and hope with others as they were mourning a loved one's death. I find his image of "leaving the door of your heart ajar" particularly poignant and apt for the grieving process.

That ambiguity of grief, changeable and poised between abject sorrow and hope, stands in stark contrast to a decision made manifest this week in the newest version of the Diagnostic and Statistical Manual of Mental Disorders. The manual's fifth edition, DSM-5, to be released at the American Psychiatric Association's upcoming convention in San Francisco, breaks with previous editions by stating that the diagnosis of major depression could apply to someone exhibiting certain aspects of grief within two weeks of the death of a loved one.

DSM's third edition, by contrast, contained an exclusion statement under Major Depressive Disorder, referred to as the "bereavement exclusion." This exclusion prevented clinicians from giving a diagnosis of depression within the first year after the death of a loved one. DSM-IV shortened the bereavement exclusion to two months, but a buffer nonetheless to prevent confusing grief's set of conditions with depression's.

For some, of course, death of a loved one can trigger clinical depression -- trigger, but it does not cause it. For most, however, grieving is long, hard work, but not a clinical condition.

By removing the "bereavement exclusion" from what had been considered the bible of the mental health world, the DSM's editors risk undermining bereavement as a universal, normal, if profoundly painful, experience. For the millions of people who are coping with the death of a child, spouse, parent, friend, or other loved one, this has serious implications.

Several of my colleagues, working recently at a meeting of the International Work Group on Death, Dying and Bereavement (IWG) in Victoria, Canada, outline important reasons why the DSM-5 change to the bereavement exclusion matters.

  1. First, normal reactions to the death of a loved one will be easily misclassified as the mental disorder depression. Grief is not the same experience as major depressive disorder. It is not an illness to be treated or cured. It is a healthy response to a painful reality that one's world is forever altered ...
  2. Second, antidepressants are commonly and frequently prescribed. There is a strong likelihood that newly bereaved people will qualify for a diagnosis of Major Depressive Disorder just two weeks after a death even though their reactions are normal. Antidepressants have not been shown to be helpful with grief-related depressive symptoms ...
  3. Third, about 80 percent of prescriptions for antidepressants are written by primary care physicians, not psychiatrists. [Some of these practitioners may] have no professional training at all in responding to the bereaved.

Based on bereavement and other changes, this fifth edition of the DSM could significantly diminish the currency of the manual with practicing psychiatrists. The National Institute of Mental Health recently withdrew its support for DSM-5, and a host of top researchers and other leaders in the field have argued and empirically demonstrated that the removal of the bereavement exclusion is ill-advised.

Still, as DSM-5 hits the shelves, I would hate to think that the public will soon be subjected to pharmaceutical ads suggesting they ask their physician whether an antidepressant might not be the right choice for them in the first weeks of their bereavement. Say my colleagues at the IWG, "Here's a better prescription: Mourn the death of your loved one in your own way."

This leads me back to the grieving husband, a member of our bereavement support community at the Visiting Nurse Service of New York, who ends his poem:

"Out of tragedy new life will come
Out of darkness will come light
I try to be brave, be strong and light the candle of tomorrow."

DSM-5 aside, no one should be expected to light that candle within weeks of a death. We each grieve in our own way, and on our own timetable. In a previous post, I outlined five steps in healthy grieving, including: letting yourself feel; acknowledging the full extent of the relationship, good and bad; building bridges to a new life; setting attainable but meaningful goals; and not being afraid to discover. With this good, hard work of grief, bolstered by a supportive community, most people mourning a loved one will make the "candle of tomorrow" glow once again.

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