I recently read Allen Frances thoughtful post questioning the possible change in DSM-V to allow the diagnosis of depression in the context of a recent bereavement. He is concerned about the medicalization of ordinary grief and the overdiagnosis and overtreatment of depression in people who are grieving.
Here I would like to briefly discuss the premise of the bereavement exemption. The premise is that the exact environmental precipitant for depression matters.
Should our diagnostic manuals make a sharp distinction between depression that is due to bereavement (normal) and depression due to other losses (a sign of a mental illness)? This makes little sense from the perspective of what we know about mood. Isn’t our mood system configured to respond in similar ways to any major loss—be it of a job, relationship, or reputation.
Whether it comes from the loss of a spouse or one’s life savings, depression is depression. I don’t see how we (myself, a psychiatrist, the DSM-V panel) can sit in judgment concerning the reasons why a person is depressed. A man loses his job at the factory after 25 years of loyal service and we consider his depression a sign of a mental illness. If another man becomes depressed after the death of a distant relative we consider his depression to be normal variation.
By my mind, it is awkward and arbitrary to judge whether a person’s depression is “normal” for a given environmental precipitant. If we are concerned about the overdiagnosis and overtreatment of depression in people who are experiencing a loss, it would make more sense to re-examine the threshold for diagnosis.
Frances argues that the threshold for diagnosis in the context of grief is too murky, “There is no bright line separating those who are experiencing loss in their own necessary and particular way from those who will stay stuck in a depression unless they receive specialized psychiatric help.” I agree, but can’t the same point be made for depression as a whole?
Right now 5 symptoms are the diagnostic cutoff for a major depressive episode but are 5 symptoms really a bright line where depression begins? Should people who have 3 or 4 symptoms of depression be turned away from treatment? Of course not. Indeed, a recent research article found that in practice small changes to the diagnostic threshold for even one symptom of depression led to drastically different rates of diagnosis.
Frances worries that medicating grief may be inappropriate because it will interfere with the process of coping and sensemaking that operate around this loss situation. I don’t disagree at all with the worry; in fact I have a bigger version of the same worry: Aren’t we too quick to medicate people who are faced with other sorts of loss situations? The bereavement exclusion has, for some time, allowed us to dodge this important question.