Imagine experiencing some or all of the following:
- Depressed mood most of the day
- Diminished interest or pleasure in daily activities
- Insomnia or hypersomnia
- Lack of energy or fatigue
- Feelings of worthlessness or guilt
- Inability to concentrate
- Recurrent thoughts of death
These are some of the criteria (along with further descriptors) for the current DSM-IV (the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders) definition of a major depressive episode. Few people experiencing these kinds of feelings, or witnessing others who do, would doubt that there may be something wrong, even if this is not construed in medical terms. But what if you had just suffered a bereavement, losing someone very close to you? Suddenly those feelings seem a whole lot more normal: a grief reaction, an understandable response to an exceptionally distressing life experience. In fact, it would be remarkable if, in the process of mourning, you did not experience at least some of those ‘symptoms’, and for quite a long period of time as you come to terms with your loss. So at what point (if any) does grief cross over into depression, a diagnosable mental illness that warrants treatment from the health services?
This question is at the crux of a big debate going on at the moment over proposals for the DSM-5 (the 5th version of the Manual, due for publication in May 2013, amidst much controversy) that seek to change the way depression is defined. In its current version, there is an explicit “exclusion criterion” for grief. That is to say, if you have these symptoms in the context of suffering a bereavement, you’re not depressed, you’re grieving. It is only if these feelings (I am reluctant to call them symptoms) continue on for longer than 2 months that a diagnosis may be sought. Even that time frame seems short, but the proposals under consideration for the DSM-5 shorten the timeframe to 2 weeks.
Critics of this move, given voice in a recent editorial in The Lancet contend that this shorter time period would inevitably create more patients, more people diagnosed with a mental illness when in fact they are experiencing a traumatic but perfectly normal and natural reaction to a difficult event. On these grounds, they argue, psychiatric treatment is a completely disproportionate response, and serves only to pathologise normal human experience. Proponents of the move counter that the mental health professions exist to alleviate suffering, and if someone is struggling to cope there is no harm in being able to identify and label their suffering with the intention of providing treatment that may help them cope and recover (here).
This debate raises two major questions of interest to the medical humanities. Firstly, what is a normal period of bereavement and at what stage might it transform into a mental health condition? Is it a matter of duration, severity of social and functional impairment, the inability to cope, suicidal ideation and ‘not wanting to carry on’? These are all important ethical and conceptual questions about the boundaries of normality and I doubt there are any clear cut answers.
Secondly, what is the role of psychiatry in society? Does it function to alleviate psychological pain and distress regardless of its cause, intensity or duration? Or should its treatments (whether pharmacological or psychotherapeutic) be used only for those suffering from ‘serious’, chronic and socially debilitating conditions? I realise as I write this that this partly depends on being able to answer the first question reliably and accurately, as there is no doubt that grief can be utterly debilitating, but yet normal.
There does seem to be a role in this debate for the medical humanities to pick apart the concepts of grief and depression, to try and better understand what, if anything, sets them apart, and how this could potentially be reflected in a diagnostic manual in a more sophisticated manner than simply pointing to duration of symptoms. Indeed, the most eloquent expression of the distinction I have come across is in the clinical psychologist Kay Redfield Jamison’s memoir of grief chronicling the loss of her husband to cancer:
The capacity to be consoled is a consequential distinction between grief and depression.
Nothing Was the Same, 2009 (reviewed here).
Worthwhile reading for the DSM-5 taskforce, perhaps?