A front page story by Ben Carey in January 24th's New York Times carries the poetic title: 'When does a broken heart become a diagnosis?' It describes a puzzling proposal by D.S.M. 5 to transform what is now considered normal grief into Major Depressive Disorder.
D.S.M. IV already recognizes that some people respond to loss with severe problems that warrant immediate attention. It therefore encourages the diagnosis of major depression whenever bereavement is persistent or is associated with severe, impairing, delusional, or suicidal symptoms. D.S.M. IV thus makes a crucial distinction between the transient pain of expectable grief and the severe and/or persistent symptoms of major depression. D.S.M. 5 proposes to eliminate this distinction. It would allow the diagnosis of major depressive disorder after only two weeks of fairly mild symptoms.
The point of departure of the Times article is a landmark review co-authored by Jerome Wakefield and just published in World Psychiatry, the official journal of the World Psychiatric Association. An accompanying editorial written by Professor Mario Maj (president of the Association) also strongly opposes the D.S.M. 5 proposal.
I asked Dr. Wakefield to summarize the findings of his review. His reply:
Dr. Wakefield goes on to point out that:
1)There is no scientific evidence to support diagnosing as major depression two weeks of grief-related depressive feelings of the kind currently excluded from diagnosis. The D.S.M. 5 literature reviews cite dozens of studies, but NOT ONE has samples of people who would get the diagnosis under the new D.S.M. 5 rules.
2) The two most rigorous studies both show that people experiencing short periods of mild grief (of the kind excluded by D.S.M. IV from the diagnosis of major depression) are no more likely to go on to further diagnosable depression than are people in the general population -- whereas real depression has a high rate of recurrence. This directly contradicts the D.S.M.-5 assertion that there is 'no difference... between grief-related depression and any other depression.'
3)There is no evidence that normal grief-related depressive feelings (of the kind now excluded from diagnosis) are associated with a greater risk for suicide.
4) Contrary to D.S.M.-5 claims that potential treatment benefits justify its proposed change, there are no controlled studies demonstrating any drug benefit for expectable grief symptoms of the kind now excluded. The D.S.M. 5 proposal could result in the over-medication of millions of the bereaved -- even though antidepressants are already under challenge as no more effective than placebo for milder depressions.
An estimated 8 to 10 million people lose a loved one every year, and something like a third to a half of them suffer depressive symptoms for up to month afterward. The proposed change would pathologize them for behavior previously thought to be normal. Until now, bereavement is one area that has been immune to the excessive encroachment of psychiatric diagnosis. This is because studies show that many depressive symptoms are common during normal grief, and it is obvious from common experience that grief after loss of a loved one can be very intense and involve depressive symptoms even when it is entirely normal.
I also asked Russell Friedman, Executive Director of the Grief Recovery Institute, to put a human face on the issue: "Imagine that your spouse of 52 years has just died. In the weeks that follow, you experience some or all of the typical reactions to this overwhelming loss. You are sad and lose interest in things. You find it hard to focus or concentrate. Your sleeping patterns are off. Your eating habits are out of whack. If you do manage to sleep, you wake up exhausted, not rested at all, and lacking energy. Your well-meaning daughter brings you to the doctor. You tell him what's going on and he quickly slaps on a diagnoses of Major Depression and prescribes pills. Drug companies will have a feeding frenzy exploiting this huge new market. They will spend hundreds of millions of dollars 'educating' doctors and the public on the D.S.M. 5 revelation that grief is a psychiatric illness. This is madness."
This is a classic case of 'if it aint broke, don't fix it' -- especially if the fix will cause many new problems. D.S.M. IV usefully distinguishes the mild, transient, and self-correcting symptoms of normal grief in contrast to the severe and persistent symptoms of clinical depression. Grief is the normal and absolutely unavoidable price we must pay for having the capacity to love -- it is most certainly not a disease. There is no reason and much risk in turning expectable grief into diagnosable mental disorder. D.S.M. 5 would cheapen the dignity of grief; substitute an impersonal medical procedure for traditional, deeply embedded cultural rituals; and result in much careless and unnecessary use of medication.
The D.S.M. 5 proposal to medicalize grief has always seemed strangely incongruous just on the face of it. Most people not hermetically sealed within the D.S.M. 5 inner sanctum immediately recognize how ridiculous it is to apply the label 'major depression' to someone after just two weeks of perfectly normal symptoms of bereavement. Hopefully, Dr. Wakefield's careful review bringing data and common sense to the issue will penetrate the D.S.M. 5 denial of the obvious. We must preserve the dignity of bereavement and protect it from the inappropriate encroachment of D.S.M. 5 diagnostic ambitions.
Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force.