These days, I get a lot of grief about grief. I am part of the work group that changed some of the ways that grief and clinical depression are described and differentiated in the new Diagnostic and Statistical Manual of Mental Disorders, typically referred to as DSM-5. That has led to a lot of conversations with colleagues who are upset about bereavement.
The other day, a friend and fellow psychiatrist—whose son had died by suicide almost a year ago—took me aside to tell me how incensed he was about the elimination from earlier DSMs of language specifying a “bereavement exclusion.” The “exclusion” essentially detailed a two-month period of “normal grief” that people would experience after the loss of a loved one. During this period, it was all but forbidden to diagnose a patient with major depression—even if the individual had all the symptoms (which are, in important and sometimes life-threatening ways, different from grief.)
This restriction was based on the best science from the mid-1980s, the last time DSM was fully revised, but the science of bereavement and major depressive disorder has changed. Our work group found the exclusion too limiting; normal grief often lasts much longer than two months, and a small subset of patients can have major depression triggered or exacerbated by a loved one’s death, just as they can from all kinds of losses and traumas.
But critics have convinced a lot of people that our goal was to diagnose every grieving person with major depressive disorder. It especially pained me to hear my friend say, "How dare they label me with depression, as though I should have been over my grief months ago? How dare they imply I should take medications to drown my sorrow?”
He missed his son intensely long after his death, thought about him frequently, and continued to experience waves of intense anguish and yearning for his son's return. He felt like a piece of him was missing and that it would never be found. He had occasional problems sleeping through the night, difficulty watching some of the TV shows he and his son had enjoyed so much together. And he had yet to return to playing golf, which the two of them had also shared. He was fully back to work and seeing patients, but he couldn’t help worrying more than in the past when caring for potentially suicidal young people.
Despite his anger, he readily accepted my hug, my offer to take him to lunch and my eagerness to listen. I told him how sorry I was for his loss, that it was impossible for me to imagine how difficult it had been for him and his wife, and that I thought his continued grief was perfectly understandable—and in no way indicative of major depression. Like most people after a loss, he needed comfort, not treatment. We agreed to meet at a later time to talk about the bereavement exclusion. It was a fascinating discussion.
I made it clear to him that the elimination of the bereavement exclusion in no way, shape or form dictates how intense his grief should be or how long it should last. His feelings were absolutely normal. I also stressed how dropping the exclusion does not re-label grief as major depression, nor does it medicalize grief. That is not to suggest that grief is not “depressing.” For many people, grief is very depressing, if by that you mean feeling sad, blue and down in the dumps. But those emotions are not the same as having a major depressive disorder, a serious clinical condition that certainly is not part of normal grief.
Our work group changed the grief language in DSM-5 to make sure clinicians and patients understand that major depression can occur in someone who is bereaved, just as it can occur in someone who is going through a divorce, facing a sudden disability or terminal illness, or struggling with serious financial troubles. There are no known clinically meaningful differences in the severity, course or treatment response of major depressive episodes that occur after the death of a loved one compared to those occurring in any other context. According to the best research available, any very stressful life event can trigger a major depressive episode in a vulnerable person; regardless of the context in which it occurs, prompt recognition and appropriate treatment can be life-promoting and even life-saving.
In addition, eliminating the bereavement exclusion in no way suggests that intense grief should be treated. Just the opposite. It makes clear, for the first time, how to spot and properly diagnose those individuals in whom major depression is triggered by the death of a relative or close friend —which is the same way we diagnose everyone else. And treatment with medications is by no means automatic or the only option. In some cases, education and support during a period of “watchful waiting” may be the most appropriate intervention; in other cases—for example, when the person has had previous bouts of serious depression, or when the major depressive episode is particularly severe and persistent—more formal treatments with evidence-based psychotherapies and/or medications might be the best option.
My friend and I discussed how these changes might affect primary care physicians, who write most of the prescriptions for antidepressants and so, technically, diagnose most depressions. One of the main concerns voiced was that the bereavement exclusion, however clumsy and unscientific, was the only thing keeping some family physicians from “giving every grieving patient an antidepressant after a 10-minute evaluation!” But we both agreed that the criteria for major depression should not be jiggered so as to anticipate poor practice by other clinicians. Instead, psychiatrists must provide more training and consultation to the other treatment professionals who might see grieving patients.
By the time our lunch ended, my friend’s view had softened. As we talked about the difference between his extended grief and a major depressive disorder, he said that it maybe was time for him to look into a suicide survivors support group. He even allowed that, given his knowledge of the potential consequences of untreated major depression, he would assess a bereaved individual who met the diagnostic criteria in the same careful way he would any other patient.
We again hugged, and then we both headed back to work. In the end, we agreed: It is time to stop grieving the loss of the bereavement exclusion.
Click here to see a video of DSM-5’s Task Force Chair Dr. David Kupfer discussing the bereavement exclusion.