Psychiatry debates whether the pain of loss is really depression

The pain of losing a loved one can be a searing, gut-wrenching hurt and a long-lasting blow to a person's mood, concentration and ability to function. But is grief the same as depression?

18 feb 2012--That's a lively debate right now, as the psychiatric profession considers a key change in the forthcoming rewrite of its diagnostic "Bible." That proposed modification - one of many - would allow mental health providers to label the psychic pain of bereavement a mood disorder and act quickly to treat it, in some cases, with medication. With the Diagnostic and Statistical Manual's fifth edition set for completion by the end of this year, the editors of the British journal The Lancet have come out in strong opposition to the new language, calling grief a natural and healthy response to loss, not a pathological state.

"Grief is not an illness. It is more usefully thought of as part of being human, and a normal response to the death of a loved one," writes the editor of The Lancet. "Most people who experience the death of someone they love do not need treatment by a psychiatrist or indeed by any doctor. For those who are grieving, doctors would do better to offer time, compassion, remembrance, and empathy, than pills."

The change under consideration would expunge any reference to the passage of time since a loved one's death before a diagnosis of depression could be considered. The current edition of the diagnostic manual states that if a patient's low mood and energy, sleep difficulties and appetite changes persist for more than two months following bereavement, a diagnosis of depression might be considered. An earlier edition of the manual had established a year as the period during which mourning should not be confused with depression.

"Putting a time frame on grief is inappropriate," The Lancet's lead editorial states simply. And in a "Perspectives" essay also published Thursday in Lancet, Harvard University medical anthropologist Dr. Arthur Kleinman agrees, eloquently exploring what's at stake.

"Is grief something we can or should no longer tolerate?" asks Kleinman, who describes his own grief after his wife of 46 years died last March from Alzheimer's Disease. "Is this existential source of suffering like any dental or back pain unwanted and unneeded?"

Kleinman calls the current two-month time period allowed for grief a "shockingly short expectation" that no religion or society would support. To allow grief to be redefined as depression with no allowance at all for the passage of time not only spells "the loss of grief": it risks redefining vast numbers of Americans who are taking their time to adjust to the loss of a loved one as sick, he writes. And it powerfully rewrites cultural values about how we understand and mark the loss of a fellow human being.

Proponents of the change have argued that it would allow the bereaved to seek help for their suffering. And they add that it would not define all who grieve as depressed. They argue there is often no difference, but for the recent death of a loved one, between the behaviors that define depression and those that define grief.

The Lancet's editors note there is no evidence that antidepressant medications improve the moods of people who are healthy to begin with. Citing fellow critics of the proposed move, Kleinman suggests that it might have been inevitable once the financial interests of pharmaceutical manufacturers collided with psychiatry's loose definitions of mental illness and the profession's tendency to expand its patient base.

"Its ubiquity makes grief a potential profit centre for the business of psychiatry," writes Kleinman.

Excess Mortality and Increased Physical Complaints Track Grieving Adults


UTRECHT, Netherlands, Dec. 6 -- Grief may not be not a disease, but bereavement is associated with a small, short-term absolute risk of mortality, researchers here report.
Action Points --->
Explain to interested patients that bereavement may trigger a number of physical and psychological symptoms.
Refer interested patients to grief or bereavement counseling when patients indicate a need for those services.
Note that not all bereaved people will benefit from counseling.
Within the six months following the death of a wife, men 55 and older have a mortality rate of about 5% compared with a rate of 3% for same-age men whose wives are still living, wrote Margaret Stroebe, Ph.D., of Utrecht University, and colleagues, in the Dec. 8 issue of The Lancet.
The researchers searched the literature for studies of grief or bereavement published after 1997 and synthesized the results for a review article on the health outcomes of bereavement. They noted that most of the studies were from the U.S., Europe, and Australia.
A number of studies have focused on an excess risk of suicide while grieving for a loved one, the investigators noted, and those studies generally confirmed an increased risk for suicide, especially within the first week of bereavement -- one study reported a 66-fold increased risk for widowers and an 9.6-fold increased risk for widows. Moreover, the increased risk was often associated with alcohol consumption.
In addition to excess mortality, bereavement was associated with a greater occurrence of physical complaints "ranging from physical symptoms (e.g. headaches, dizziness, indigestion, and chest pain) to high rates of disability and illness," the authors wrote.
But while some studies found that these symptoms led to increased use of medical services, a number found no corollary with increased use of medical services, and, in one study of grieving women, doctors' visits actually decreased.
In general, the authors said, the literature indicated that "many of those with intense grief might fail to consult doctors when they need to do so."
Psychological reactions to grief, they wrote, "are diverse, varying between individuals as well as between cultures and ethnic groups."
Most people have "acute suffering, particularly early on in bereavement," but in general people are resilient and suffering abates with time. However, the researchers said, in a minority of bereaved individuals "depression reached clinical importance, with findings of studies suggesting that 25-45% have mild levels of depressive symptoms and 10-20% show clinical levels."
And when the loss of life was especially traumatic or horrific, there is a risk of posttraumatic stress disorder among the bereaved, they wrote. For example, in a study of parents whose child had died, 27.7% of mothers and 12.5% of fathers met the diagnostic criteria for posttraumatic stress disorder five years after the child's death.
It is not clear how often bereavement progresses to complicated grief -- estimates range from a low of 9% to a high of 78% reported among people bereaved by suicide or accidents -- but it may be more likely when grief occurs in the presence of other mental health disorders.
The criteria for complicated grief include chronic and disrupting yearning for the deceased individual, inability to accept the death, inability to trust others, detachment, and agitation.
Additionally, the researchers said, symptoms of grief interfere with normal social or occupational functioning and the symptoms persist for six months or longer.
They concluded that there was "no evidence that all bereaved people will benefit from counseling."
They suggest this strategy:
Create an accessible infrastructure of grief counseling organizations, but in general leave the initiative for seeking services to the bereaved individual.
Consider interventions for high-risk individuals such as those with a history of mental illness, people grieving deaths by suicide or accident, and parents grieving the death of a child.
Consider gender differences, especially widowers versus widows, when assessing the implications of grief.
Finally, the authors concluded, there was a need for "improvement in the design of intervention studies and for strict assessment of their effectiveness following evidence-based treatment criteria."
The authors declared no conflicts of interest and did not disclose a funding source for the review.
Primary source: The LancetSource reference:Stroebe M, et al "Health outcomes of bereavement" Lancet 2007; 370: 1960-73.