The American Psychiatric Association (APA) may soon redefine what we know as grief to depression, if symptoms last more than two weeks. The APA is the agency that literally writes the book on mental disorders, the Diagnostic and Statistical Manual of Mental Disorders or DSM. Their words shape how doctors practice medicine, health insurance coverage and society's views of mental diseases. In the current version of the DSM, the definition of a major depressive episode excludes situations that are clearly signs of bereavement. But the proposed changes to the latest version of the DSM may allow grieving patients to be lumped in with those diagnosed with major depression.
Could this change in the definition allow patients, who would otherwise be denied treatment, to receive the help they sought?
The answer isn't clear. It would certainly make more people eligible for anti-depressant treatment. Mental health decisions are often difficult to make, by doctors and patients alike. When a patient comes to me with symptoms of depression it can be hard to know when to provide counseling alone and when to intervene with a behavioral change, dietary supplement or drug. The length and severity of the symptoms suggest the level of intervention needed, but everything has to be seen within the greater context of that person's life. Simply calling grief "depression" blurs the distinction that the two have, it removes the context. Scientists from NYU and Columbia University have similar qualms with the removal of the "bereavement exclusion," citing that scientific research has failed to prove that grief and major depression are the same.
What unintended consequences could this change have on patients?
A diagnosis of depression can stick with people a long time, because most people think of it as a recurring illness. The thing about grief is that it ends. Sure, it may return when another loss happens, but I haven't seen grief-induced depression follow the same course as other forms of depression.
Do feelings of sadness felt after a loss have a purpose? Does the disruption of one's life serve as a cue for something greater? Could chemical intervention too early undermine some of the positive changes that come from these experiences (eg: a feeling of self-reliance and resilience)? Is there a possibility we are prolonging our process of creating closure? Does two weeks truly reflect a normal time-frame for the symptoms of grief to resolve on their own?
I don't propose to know the answers to these questions. I know an essential part of being a doctor is helping to relieve suffering, and I think this should always be considered in the terms of a person's remaining lifetime. I'm hesitant to intervene with something that could potentially drag out the suffering, or be completely unnecessary. I think we're short-changing people suffering from depression, and grief, not to mention the judgment of our clinicians by lumping these diagnoses together, and hope the American Psychiatric Association vetoes this change.
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