Living with grief
An EditorialThe Lancet
18 February 2012
When should grief be classified as a mental illness? More often than is current practice, proposes the American Psychiatric Association in its forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Previous DSM editions have highlighted the need to consider, and usually exclude, bereavement before diagnosis of a major depressive disorder. In the draft version of DSM-5, however, there is no such exclusion for bereavement, which means that feelings of deep sadness, loss, sleeplessness, crying, inability to concentrate, tiredness, and no appetite, which continue for more than 2 weeks after the death of a loved one, could be diagnosed as depression, rather than as a normal grief reaction.
The death of a loved one can lead to a profound, and long-lasting, grieving process, which is movingly described in an essay by Arthur Kleinman in this week’s Art of Medicine section. After his wife died, it took 6 months before Kleinman’s feelings of grief became “less acute” in his own words, and almost a year on, he feels “sadness at times” and harbours “the sense that a part of me is gone forever…I am still caring for our memories. Is there anything wrong (or pathological) with that?”
Most people’s experiences of grief would align with Kleinman’s. It is often not until 6 months, or the first anniversary of the death, that grieving can move into a less intense phase. Grief is an individual response to bereavement, which is shaped by the strength of relationship with the person who has died, being male or female, religious belief, societal expectation, and cultural context, among other factors. Malcolm Potts, in an essay in this journal in 1994, after the death of his wife, said: “Grief is an astonishing emotion. It is the tally half of love and it has to be….Anguish, body-shaking weeping, grief: a biological behaviour that had been latent and unused in my brain…I would not and could not forgo it. Grief has to be.” 18 years after his stillborn daughter was born, Steven Guy said: “I have moved on; I can talk about the day she died and not cry, sometimes…She has changed me from the shy insecure person I was then to the openly emotional, caring, supportive, and strong man I am now.”
Medicalising grief, so that treatment is legitimised routinely with antidepressants, for example, is not only dangerously simplistic, but also flawed. The evidence base for treating recently bereaved people with standard antidepressant regimens is absent. In many people, grief may be a necessary response to bereavement that should not be suppressed or eliminated. For some, though, whose grief becomes pathological (sometimes known as complicated or prolonged), or who develop depression, treatment with drugs or, sometimes more effective psychological interventions such as guided mourning, may be needed. WHO’s International Classification of Diseases, currently under revision as ICD-11, is debating a proposal to include “prolonged grief disorder”, but it will be another 18 months before that definition will be clear. Bereavement is associated with adverse health outcomes, both physical and mental, but interventions are best targeted at those at highest risk of developing a disorder or those who develop complicated grief or depression, rather than for all.
Building a life without the loved person who died cannot be expected to be quick, easy, or straightforward. Life cannot, nor should not, continue as normal. In a sense, a new life has to be created, and lived with. After the loss of someone with whom life has been lived and loved, nothing can be the same again. In her memoir to her husband, Nothing was the same, Kay Redfield Jamison, comments: “There is a sanity to grief” in contrast to her own experience of bipolar disorder. In Kleinman’s words, “My grief, like that of millions of others, signalled the loss of something truly vital in my life. This pain was part of the remembering and maybe also the remaking. It punctuated the end of a time and a form of living, and marked the transition to a new time and a different way of living.”
Grief is not an illness; it is more usefully thought of as part of being human and a normal response to death of a loved one. Putting a timeframe on grief is inappropriate—DSM-5 and ICD-11 please take note. Occasionally, prolonged grief disorder or depression develops, which may need treatment, but most people who experience the death of someone they love do not need treatment by a psychiatrist or indeed by any doctor. For those who are grieving, doctors would do better to offer time, compassion, remembrance, and empathy, than pills.
Misconceptions about the proposal to eliminate the grief exclusion criterion from DSM-IV have been presented online and in the media. Writers have expressed fear that the change will lead to automatic diagnosis of individuals who are grieving with Major Depressive Disorder. I would like to provide some background on the grief exclusion and some insight into thinking behind the proposal to remove it for DSM-5 in order to put this change into perspective.
First, the grief exclusion criterion – which states that someone who has experienced a recent bereavement is not eligible for a diagnosis of major depression – was not present in the two major psychiatric diagnostic systems that formed the basis for the DSM-III – the diagnostic manual that is the immediate precursor of our current DSM-IV. Rather, it was added to DSM-III largely on the basis of the work of one of the DSM-III task force members who was then studying grief and was carried forward with little modification into DSM-IV. Second, the other major psychiatric diagnostic system used in the world – the International Classification of Diseases – has never had a grief exclusion criterion for major depression.
Third, a broad range of evidence agreed to by both sides of this debate shows that there are little to no systematic differences between individuals who develop a major depression in response to bereavement and in response to other severe stressors – such as being physical assaulted and raped, being betrayed by a trusted spouse whom you learn has been unfaithful or a beloved child whom you are told is dealing drugs, having your doctor tell you that your breast or prostate biopsy for cancer is positive or the loss of your treasured job. So the DSM-IV position is not logically defensible. Either the grief exclusion criterion needs to be eliminated or extended so that no depression that arises in the setting of adversity would be diagnosable. This latter approach would represent as major shift, unsupported by a range of scientific evidence, in the nature of our concept of depression as epidemiologic studies show that the majority of individuals develop major depression in the setting of psychosocial adversity.
Fourth, 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. Finally, diagnosis in psychiatry as in the rest of medicine provides the possibility but by no means the requirement that treatment be initiated. Watchful waiting is important tool for all skilled clinicians. As a good internist might adopt a watch and wait attitude toward a diagnosable upper respiratory infection assuming that it is unlikely to progress to a pneumonia, so a good psychiatrist, on seeing an individual with major depression after bereavement, would start with a diagnostic evaluation.
If the criteria for major depression are met, then he or she would then have the opportunity to assess whether a conservative watch and wait approach is indicated or whether, because of suicidal ideation, major role impairment or a substantial clinical worsening the benefits of treatment outweigh the limitations. As with the psychiatric response to the other major stressors to which we humans are all too frequently exposed, good clinical care involves first doing no harm, and second intervening only when both our clinical experience and good scientific evidence suggests that treatment is needed.