1 Boring Old Man

DSM-5 To The Barricades On Grief
^{Defending The Indefensible}
DSM-5 in Distress: Psychology Today
by Allen Frances
February 18, 2012

The storm of opposition to DSM 5 is now focused on its silly and unnecessary proposal to medicalize grief. DSM 5 would encourage the diagnosis of ‘Major Depressive Disorder’ almost immediately after the loss of a loved one- having just 2 weeks of sadness and loss of interest along with reduced appetite, sleep, and energy would earn the MDD label [and all too often an unnecessary and potentially harmful pill treatment]. This makes no sense. To paraphrase Voltaire, normal grief is not ‘Major’, is not ‘Depressive,’ and is not ‘Disorder.’ Grief is the normal and necessary human reaction to love and loss, not some phony disease.

All this seems perfectly clear to just about everyone in the world except the small group of people working on DSM 5. The press is now filled with scores of shocked articles stimulated by two damning editorial pieces in the Lancet and a recent prominent article in the New York Times…

• DSM-5 Mood Disorder Work Group
• Living with grief
• Lancet Rejects Grief As a Mental Disorder
• APA President’s Defense [requires free sign-up]
• Media coverage of UK concerns over DSM-5
• Can the Press Save DSM 5 from Itself?
• DSM-5 To The Barricades On Grief

"When we say that we are recommending removing this exclusion of grief from the diagnosis of depression, people have misinterpreted this to mean that therefore everyone who is grieving after the loss of a spouse will be diagnosed as depressed. That is not at all the case," he said. Dr. Oldham also made the point that in general, people who are under a lot of stress or are going through a rough period are not necessarily going to be diagnosed with depression.

"Even if you meet the criteria for depression, it doesn’t mean that you’re going to have treatment slapped on you. It just means that maybe you’d have a conversation about it with your doctor and perhaps agree to a watchful waiting period and be alert to how things go and maybe check in a little more frequently. Nothing is automatic; there are lots of options." The bottom line, Dr. Oldham said, is "we want people to get treatment who need it."

"What we know," Dr. Oldham said, "is that any major stress can activate significant depression in people who are at risk for it. It doesn’t make sense to differentiate the loss of a loved one as understandable grief from equally severe stress and sadness after other kinds of loss."

As long as we’re parsing his words, "What we know is that any major stress can activate significant depression in people who are at risk for it." He doesn’t "know" that. If I get depressed after a severe stress, I was at risk for it? It’s a tautology – the definition contains itself. A psychoanalyst might interpret that as based on my previous life experience. A biologist might think it’s in my genes. A neuroscientist may point to my brain pathways. But all are assuming predisposition based on my reaction. Maybe. Maybe not. It’s an assumption, not something anyone "knows." For all I know, the rest of you have something wrong – too much denial, or a faulty brain pathway, or a missing gene. But I wander from my point. Back to the thread. If depression in response to a severe stress is, in fact, a particular syndrome as opposed to depression in the absence of a severe stress, the sensible thing to do would be to make that distinction in our diagnostic criteria of depression rather than remove any sign of it, or for that matter, remove "depression" as part of a normal, human process eg bereavement.