grief versus depression {12/4/12}

As you may or may not know, the DSM-5 (the American Psychiatric Association's latest diagnostic manual) has been finalized and will be released this spring. It's been about twenty years since the last DSM was released, and obviously there have been a lot of changes in the psychiatric community. Antidepressants have become as abundant as vitamins. Autism diagnoses have skyrocketed. Treatment of children for a variety of psychiatric disorders has become commonplace (though controversial). As someone who has experienced a significant range of psychiatric treatment--both as a teen and adult, both as a patient and a family member/friend--I am naturally interested in all the changes in the latest DSM. But as a survivor of suicide, I am especially concerned about one: the Bereavement Exclusion.  

The Bereavement Exclusion is a sort of clause in the Major Depressive Disorder entry of the current DSM. It basically exists because grief can have symptoms similar to those of MDD, and should not be treated as though it were depression. While drawing a distinction between grief and depression, the current DSM does recognize that grief can trigger a major depressive episode, and that grief that does not improve over time or that exhibits extremes (such as suicidal ideation) may need treatment. 

The Bereavement Exclusion has been removed from the DSM-5. Why? "The “rationale” section on the DSM-5 website’s major depressive episode page explains that the reason for eliminating the BE is that “evidence does not support separation of loss of loved one from other stressors”. The website cites only one reference as the basis for this proposal, a review paper by Zisook and Kendler that claims that bereavement-related depressions are generally similar to standard depression."

What does this mean? One could say it suggests that if you are still feeling sad two and a half weeks after the death of your mother, or spouse, or child, a psychiatrist could chuck some pills at you and send you on your way.

Am I suggesting that?

Yeah, I guess I am.

I have some conflicting opinions when it comes to the differences between grief and depression. Some days I'm not sure there are any. As life is a constant exercise in loss, in a broad sense, grief could be seen as the root of all depressive disorders. My first major depression occurred after my family moved from Detroit to Alabama, and was a result of grieving the home, friends, and family we left behind. 

Here's the tricky part: there are different kinds of grief and different kinds of loss. Grieving my brother's suicide was nothing like grieving my grandparents. Grieving my brother took somewhere between four and six years, and it completely changed my life. Those changes hurt while they were happening--they tore my heart wide open. But now, I am thankful for them. What if they hadn't been allowed to occur? What if they had been chemically suppressed? What if I'd gone on with my life thinking I was supposed to feel "better," "normal," "happy," and "ok"?

Something else, perhaps an even more compelling argument for keeping the Bereavement Exclusion: I was on antidepressants at the time of my brother's death. I continued taking them for two years, and I continued fighting against my grief. I tried to do all the things the DSM would have considered "healthy" and "normal": hold down a job, spend time with friends, get on with my life. I struggled and I failed. It wasn't until after I stopped taking medication that I was able to feel the full force of my grief and move through it. Dampening my feelings only prolonged the process.

I'm not an expert. I haven't conducted any research studies. Maybe I'm the .001% weirdo that doesn't fit the mold. But I tend to doubt it. I certainly think that suicidal ideation in ANY context needs to be treated. But lumping grief in with depression, treating loss with pills...I'm not convinced it doesn't do more harm than good.

Guess we'll see in twenty years?