1 Boring Old Man

Living with grief
^{An Editorial}

The 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.