When someone we love dies, it hits us hard. When it’s our child, it annihilates us. It’s not surprising then, that traumatic grief makes us feel we’re going crazy. Often, and understandably, we turn to medical professionals for help.
When my son was killed, I didn’t know how to manage my suffering. Two months post-loss, I went to my physician and she asked me:
“Are you sick, or are you grieving?”
I looked at her. I saw the problem. Who decides? What are the criteria?
So I answered: “Part of me has died and it hurts so much I don’t think I can make it.”
I was in excruciating pain. In the first years after Alex was murdered, I often felt like I was actually having a heart attack my heart was so broken. But I knew I wasn’t depressed. I was in shock and then later, utterly lost in deep, traumatic grief.
As the months passed, the sorrow did not disappear but instead became a part of me. I now know that I will grieve the death of my son for the rest of my life.
In fact, most people who are grieving are not depressed but instead… grieving. Very different. Even clinicians agree that grief is not the same as clinical depression.
Only in certain cases does grief sometimes trigger MDD (major depressive disorder). This is very much the exception, not the rule.
Yet, the grief scorecard used by primary care physicians and psychiatrists in the US says otherwise. In May 2013, the American Psychiatric Association released the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). In it, the bereavement exclusion criterion for MDD (major depressive disorder), which had existed in previous editions, was removed.
Originally, the bereavement exclusion was introduced in the DSM-III and was for the first year after a loss. That was then reduced to two months in the DSM-IV. It was the decision to drop the bereavement exclusion altogether in DSM-5 that created a firestorm in the media and medical profession.
It had the effect of suggesting to many that grief was not a natural, adaptive response to the loss of a loved one. In a nutshell, it pathologized grief.
This means that today if you present with symptoms such as deep sorrow, loss of appetite, crying, insomnia, wanting to be with your dead child or loved one… after two weeks post-loss, you can be diagnosed with a mental disorder.
This was a major revision of the DSM. To put it in perspective, there hadn’t been such a controversial change in diagnostic criteria since the depathologization of homosexuality.
Proponents of the change argued that the removal of the exclusion was necessary. They said that the DSM-5 now allowed a person who met the full symptom criteria for MDD to no longer be denied that diagnosis, solely because he or she had recently lost a loved one.
Meanwhile, opponents of the change were concerned that medicalizing grief “might distort the normal process of adjusting to a loss as well create a harmful dependence on anti-depressants.”
My view? A time span of two weeks post-loss is an obscenely short period of time to allow for a confident diagnosis of major depression. It’s so ridiculously short it belies belief.
I’ll readily admit that there will always be an element of clinical judgment in rendering a medical diagnosis of any kind. Yet, it seems to me that the DSM-5 has got it very wrong on this point.
It’s delusional to think you can diagnose a grieving person with an illness two weeks after they’ve lost someone they love or their child.
And I’m not the only one who thinks this. In 2012, The Lancet editorial stated: “medicalizing grief, so that treatment is legitimized routinely with antidepressants, for example, is not only dangerously simplistic, but also flawed.”
Whether someone who is grieving is also suffering from major depression is something that should only be ascertained over an extended, lengthy period of time. Two weeks post-loss is absolutely not a viable period to diagnose anything other than major earth-shattering grief and that is most definitely not a disorder.
An unsurprising consequence of the changes in the DSM-5 is that many clinicians nowadays medicate normal grief, when what’s needed is compassion, understanding, and space to grieve. As Dr. Joanne Cacciatore wrote back in 2012:
“The DSM-5 change increases the likelihood that grief will be misdiagnosed as Major Depressive Disorder in the most vulnerable of all populations…Recent trends suggest that the most common form of treatment offered for this disorder is psychotropic medication”.
Unfortunately, many medical systems today require a diagnosis of mental or physical illness before a patient can access the help they need. In most cases, insurance companies won’t cover the cost of grief counselling unless a diagnosis is made.
It’s therefore easy to see why medicating someone who is in acute, emotional pain happens so often. It’s a short hop from diagnosis to pills.
It’s quick and, dare I say it, profitable.
I count myself lucky — in Switzerland and many parts of western Europe, it’s not a given that you’ll be prescribed anti-anxiety or anti-depressant medication following the death of a loved one. My doctor gave me a bag of scented candles, bath salts, signed me onto one year’s worth of physiotherapy for my back, circulation, and emotional wellbeing. She gave me a hug, then sent me on my way.
The only meds I got were for high blood pressure as she truly feared I’d collapse before I got back to my car.
For many, my plight might seem to be the height of bad luck. Maybe they’re right. Maybe I suffered unnecessarily and continue to suffer more than I would have done had I been on medication. I can’t be sure, but I doubt it.
The fact is, grief hurts. Child loss is agony. Psychopharmaceuticals won’t bring back my Alex and current research doesn’t support the commonly-held belief that they are effective for grief.
I grieve because I must. My love for my child demands my full attention, in my heart and mind. It was always so, from the moment I knew of my son’s existence.
The fact that he’s dead has not changed me as a mother but it has changed me as a person. I don’t believe drugs would have facilitated my acceptance of this new reality and indeed, may well have hindered it.
The arguments put forward by some in the medical field, such as Professor Ronald Pies, MD, don’t sit well with me. He suggests that: “Clinical judgment may warrant deferring the diagnosis for a few weeks, in order to see whether the bereaved patient ‘bounces back’ or worsens”.
Sorry, no. I’m not ‘bouncing back’ from child loss. And to suggest that unless I do, I must be suffering from a mental disorder, is disingenuous.
In the 2015 editorial of the American Family Physician, Michael G. Kavan, Ph.D. rightly pointed out that:
“Eliminating the bereavement exclusion criterion will also result in an increasing number of persons with normal grief to be inappropriately diagnosed with MDD after only two weeks of depressive symptoms. Not only is the grieving patient now stigmatized with a mental health disorder, but clinicians may unnecessarily prescribe antidepressant medications, exposing patients to the associated adverse effects. With nearly 2.5 million deaths each year in the United States, the harm associated with the inappropriate diagnosis and treatment of grieving patients is apparent and disturbing.”
There are so many different ways to grieve, and all are painful. There may well be cases where medical intervention is indicated and a multi-disciplinarian approach of support, clinician-led therapy, and medication is warranted. But the fact remains that grief is not a mental disorder.
The bereaved need compassion and kindness. We need a surrounding that holds space for our grief, that is willing to witness our sorrow, and stays connected to us as we suffer exposed in our vulnerability.
I know that’s not an easy thing to find in this mourning-avoidant society but comfort and understanding are there out there, and if not with our families and friends, then in online forums, Facebook pages, and local support groups.
If we seek medical help and counseling, we should be afforded proper, impartial advice. We deserve to have an honest, unbiased conversation with our clinician.
If that’s not possible, we should seek out another medical provider.
It’s up to us how we live with our grief.
And that’s the point, isn’t it? Our grief, our life, our informed decision.
Published on Still Standing Magazine 22.08.2019