Psychiatrists charged with revising the official "Bible" of mental illness are recommending changes that would make it easier for doctors to diagnose major depression in the newly bereaved.
Instead of having to wait months, the diagnosis could be made two weeks after the loss of a loved one.
The current edition of the Diagnostic and Statistical Manual of Mental Disorders - an influential tome used the world over - excludes people who have recently suffered a loss from being diagnosed with a major depressive disorder unless his or her symptoms persist beyond two months. It's known as the "grief exclusion," the theory being that "normal" grief shouldn't be labelled a mental disorder.
But in what critics have called a potentially disastrous suggestion tucked among the proposed changes to the manual, "grief exclusion" would be eliminated from the DSM.
Proponents argue that major depression is major depression, that it makes little difference whether it comes on after the loss of a loved one, the loss of a job, the loss of a marriage or any other major life stressor. Eliminating "grief exclusion" would help people get treatment sooner than they otherwise would.
But critics fear that those experiencing completely expectable symptoms of grief would be labelled mentally "sick." Dr. Allen Frances says the proposal would pathologize a normal human emotion and could bring on even wider prescribing of mood-altering pills.
"This is a disaster," says Frances, a renowned U.S. psychiatrist who chaired the task force that wrote the current edition of the DSM, which is now undergoing its fifth revision.
"Say you lose someone you love and two weeks later you feel sad, can't sleep well, and have reduced interest, appetite, and energy. These five symptoms are completely typical of normal grieving, but DSM-5 would instead label you with a mental disorder."
And, according to Frances, there's no problem with the current grief exclusion that needs fixing. The DSM already allows the diagnosis of major depression soon after a loss if the grief symptoms are severe - when the bereaved becomes incapacitated, suicidal or psychotic.
Milder symptoms, he says, are better lived through than treated with a pill.
But if the proposed change is allowed, "your psychiatrist or your primary care doctor - more likely your primary care doctor who sees you for less than 10 minutes - can decide that you have major depressive disorder, stigmatize you with an inaccurate label, and prescribe an unnecessary medicine," Frances says.
It would turn profound love into a disease, he says, "and ignores the inescapable fact that grief is the necessary price we pay for our mammalian capacity to love."
The next version of the DSM is due out in 2013. The first, published in 1952, was a thin, 132-page spiralbound volume containing 128 disorders. Its current edition, published in 1994, lists 357 disorders, and runs 886 pages.
Every revision brings fresh controversies. Under the changes being recommended for the upcoming fifth edition, children with frequent temper outbursts and a persistent "negative mood" could meet criteria for a new illness called "temper dysregulation disorder with dysphoria," or TDD. A new category called "behavioural addictions" would be created, beginning with gambling, but with Internet and sex addiction recommended for inclusion in the appendix as conditions worthy of further study.
Dr. Kenneth Kendler, a member of the work group behind the proposal to eliminate the grief exclusion for major depressive disorder, says the change would not lead to the wholesale diagnosis of the bereaved with major depression.
In a statement published on the DSM-5 website, Kendler says the vast majority of people exposed to grief don't develop major depression. It's not a matter of feeling "sad" or "blue," he says.
"Major depression - the diagnostic term - is something quite different." Even then he says a diagnosis by no way means doctors should rush to treat. Rather, he says physicians could adopt a "watch and wait" approach and intervene only when experience and "good scientific evidence" suggests it's warranted.
That offers little comfort to critics, who say that, in the "real world," the DSM is used by family doctors with limited time for patients or training in psychiatry.
"If grieving interferes with your life in a major way and your functioning is seriously impaired, then, OK. Psychiatry and psychology have a role," says Dr. Frank Farley, a past president of the American Psychological Association and a native of Edmonton.
"But it's going to open up the Pandora's box of pharmaceuticals. Is that the way to go with grief?"
Farley lost his first wife almost three decades ago, a woman he loved "madly."
"And I still think of her a lot. I don't view that even remotely as a pathology," says Farley, a psychologist at Temple University in Philadelphia.
"The DSM system is taking too much of the richness and diversity of human behaviour and putting negative labels on it."
http://www.montrealgazette.com/health/GRIEF+DISORDER+disorder/4633225/story.html
