In 2012, a panel of psychiatrists working on the Diagnostic and Statistical Manual (DSM) of Mental Disorders voted to remove the “bereavement exclusion” from major depression diagnoses.
The DSM guides psychiatrists, family care physicians and other prescribers of medicine in treating mental health conditions.
The “bereavement exclusion” kept doctors from diagnosing grieving patients with depression until at least two months passed following a death. That two month waiting period also kept doctors from prescribing anti-depressant medication to their patients. But now that the DSM has been changed, doctors can prescribe anti-depressants to patients during that time.
Since this change to the DSM, there has been intense debate in mental health treatment circles about the use of anti-depressants in people who are grieving. One of the strongest voices against prescribing anti-depressants during this time frame is Dr. Donna Schuurman; the CEO of the Portland based Dougy Center, the National Center for Grieving Children and Families. Schuurman says prescribing anti-depressants to bereaved patients amounts to giving them “grief pills.”
“We are moving in the bereavement world towards making grief a mental disorder,” Schuurman says.
Schuurman says people are prone to seek “quick fixes” to deal with loss, sadness, anger and other emotional adversity. She adds that by changing the DSM, the mental health community can now make it easy for people to take an anti-depressant pill instead of dealing with their grief. “
Grief is a normal response to loss,” Schuurman says. “Losses of all kind. Whether it’s loss of relationship, losses through death, loss of hope…We’re all going to face losses throughout our lifetimes, and ultimately, the big loss, which is our own life. [But the change to the DSM] means that people who have a death are more likely than not to be diagnosed with major depressive disorder and the major treatment for that is anti-depressants.”
Lack of Grief-Training
One of the concerns Schuurman – and other grieving experts have -- is a perceived lack of grief training. “Most therapists, most mental health workers, psychiatrists, and school counselors – people who regularly deal with children for example, have little or no training in grief or loss,” Schuurman says.
That lack of training could lead some counselors and psychiatrists to make referrals for depression, when in fact the underlying issue is grief. The mental health community has long struggled with the question of whether “down” behavior in a patient experiencing a death is indicative of grief or depression. “Grief and depression are not the same thing,” says Dr. Katherine Shear, the Marion Kenworthy Professor of Psychiatry at Columbia University’s School of Social Work. “And it’s very interesting because a lot of people do confuse them.”
Jerome Wakefield of the NYU Silver School of Social Work and Department of Psychiatry agrees that the conditions are different. When the changes were initially made in the DSM, Wakefield told NPR he was concerned people grieving would be given medication to fight depression.
“To a lot of us this just seems like a gross error of psychiatric classification that might allow patients to be given medication, to be diagnosed, to be seen differently than for what they really may going through,” Wakefield told NPR.
Timing is Essential
While Dr. Katherine Shear of Columbia University agrees with Schuurman and Wakefield that grief and depression are two different emotional conditions, she disagrees with her colleagues when it comes to treating depression in grieving patients with medication.
Shear makes a strong argument that depression can actually keep people from properly grieving. The emotional role of grieving, Shear says, is for people to re-define their relationship with the person they lost. “You have to re-envision your life moving forward in a way that still has the possibility for joy and satisfaction,” Shear says. “And that all has to happen during a period after the person dies. But one of things that can slow that process really badly is if an episode of major depression is triggered.”
Shear gives this example of productive grief: a man lost his wife of many years. Shear’s daughter was close to the wife. Shear and her daughter went to visit the man at this home. “He took one look at my daughter and he burst into tears,” Shear says. “And she started to cry, and it was a very emotional moment, and then the intense emotion receded. And they started talking about the teacher and some of the wonderful things, and he actually seemed to enjoy that conversation again.” That, Shear says, is grief. There are intense emotions of sorrow in the person’s passing and joy in remembering the person.
Shear gives another example of a woman who lost her husband. Shear went to visit the woman at her home. “And I went over to talk to her,” Shear says. “And she kind of looked at me and said, ‘I don’t know what’s wrong with me, but I just don’t feel much of anything.’”
That numbness Shear describes is a sign of depression, and that depression can keep people from grieving.
Essentially, Shear says, those patients never imagine their lives without the person who passed, because they are unable to reimagine their relationship with the person who died. “We have to be able to move on,” Shear says. Donna Schuurman agrees that grieving helps people move on from loss – and both Schuurman and Shear say grief – or expressions of grief-- is often taboo conversation. But while Shear says doctors need anti-depressants as a tool in their kit to help people get to a place to grieve, Schuurman believes it will now be used as a grief-pill to shortcut the feelings of loss and sadness.
“We want quick fixes,” she says. “The point of life isn’t to be happy, the point of life is to find fulfillment, which often doesn’t necessarily lead to happiness.”