In the opinion pages of today’s New York Times the former chairman of psychiatry at Duke and DSM-IV architect Allen Frances writes a passionate plea to the architects of DSM5 not to inadvertently medicalize normal grief. Although I’d made a promise to myself not to keep referencing major press outlets in the blog (because everyone has access to them), this one was too good to pass up. The controversy surrounds the loosening of the criteria for what counts as Major Depressive Disorder (MDD) — what we in mental health call depression. Frances points out that in drafts of the DSM5, if normal grieving (e.g., following the death of a loved one) carries on for more than two weeks, the person grieving would be diagnosable with MDD.
What would this mean? Well, for starters, it would be a windfall for pharmaceutical companies. But no, there’s no real conspiracy here. As Frances explains:
It is not that psychiatrists are in bed with the drug companies, as is often alleged. The proposed change actually grows out of the best of intentions. Researchers point out that, during bereavement, some people develop an enduring case of major depression, and clinicians hope that by identifying such cases early they could reduce the burdens of illness with treatment.
Ah, good intentions… This is a good example of a fine line that comes up often in mental health: that between prevention and over-diagnosis. If the discussion at this year’s American Psychiatric Association meeting is any barometer, this is a major discussion within the various groups designing DSM5. We want to catch mental illness before it becomes full-blown, but we also don’t want to diagnose someone who is sad or troubled for really good reasons and will heal on their own (and maybe even grow out of their grief). Frances:
The bereaved would also lose the benefits that accrue from letting grief take its natural course. What might these be? No one can say exactly. But grieving is an unavoidable part of life — the necessary price we all pay for having the ability to love other people. Our lives consist of a series of attachments and inevitable losses, and evolution has given us the emotional tools to handle both.
… Humans have developed complicated and culturally determined grieving rituals that no doubt date from at least as far back as the Neanderthal burial pits that were consecrated tens of thousands of years ago. It is essential, not unhealthy, for us to grieve when confronted by the death of someone we love.
I think here Frances misses something (or at least here he misses something — he’s a pretty smart guy, so he probably doesn’t really miss this): taking medication for sadness and stress has become a “culturally determined grieving ritual” for many people in the US. Does that mean that we should accept the medicalization of normal emotions? Of course not. It only means that we should recognize that for many, it has become part of our culture, and turning the tide will take more than rewriting drafts of DSM5.