Depression and Grief: Good Riddance to the Bereavement Exclusion
Ashes, Forgiveness, Grief, Letting Go, Emmaus.
Helen has been leading a church retreat, one night a week over five weeks. The topic for the third week was grief, which got me searching out some writing I once did about the bereavement exclusion in the DSM, Diagnostic and Statistical Manual used in psychiatry in the United States.
Before the DSM-5, the bereavement exclusion was used in the process of diagnosing depression. The assumption was that grief and clinical depression look alike, so doctors can’t tell the difference between them. If somebody who had a significant loss in the previous two months appeared in the office, the diagnosis of depression could not to be made.
The draft DSM-5 indicated its intention to drop the exclusion. In other words, if a widow appears in the doctor’s office within two months of her husband’s death, the doctor should go ahead and figure out whether she had clinical depression.
That issue got a lot of mental health practicioners worked up, bolstered by grieving parents who said that their grief was normal, and they were not mentally ill. There still exists this conflict within psychiatry, with some claiming that normal feelings are being medicalized and medicated.
I have been living with depression nearly seven decades and writing about it for sixteen years. So I followed this debate with interest. When I was rapid cycling in and out of depression—and then my mother died—I figured I had some personal experience to bring to bear on the issue.
Background: my mother lived in Costa Rica. She and my sister owned and operated a hotel/restaurant called the Pato Loco. That is where Mama died. I also owned a home and spent significant time there.
Was I experiencing grief or depression?
I was boarding the plane, rushing to arrive before she died when I got the call. I was too late. I burst into loud and public tears.
These are telltale signs that my grief occupied different psychological territory than my previous and subsequent depressions:
My grief came and went in waves. There were those sudden bursts into tears in public places, but they passed.
I was consolable. I could have fun.
I could remember the good times, the funny stories, as well as the tragedies.
I did not feel isolated. I drew closer to my sister. The people who hung out at the Pato Loco told me they felt they got to know me better in those two weeks while I helped deal with Mama’s possessions than in the years I had been coming to visit.
I knew it was passing, that it would get better.
A month later it was different. I was back to the illness that was utterly defeating me:
The pall hung over the whole day, every day. No relief.
When I did things for fun, I really was just going through the motions. I felt dead.
Darkness tinged every memory.
I did not contact my closest friends. I wanted to quit therapy.
I did not believe I would ever get better.
What implications follow for the bereavement exclusion:
· First, grief and depression are not the same. Indeed, it is true—most people in grief do not have depression. So their comments about not having depression are not to the point.
· People who do have depression sometimes lose loved ones, too. They deserve treatment.
· In fact, they need treatment. The isolation and the numbness of depression prevent people from grieving normally. Depression cuts them off from their support systems and their feelings. It interferes with the normal grief process of integrating the loss and rebuilding a life.
· Depression is a risk factor for suicide, one of the greatest. Bereavement also is a risk factor for suicide. One risk factor layered on top of another is not an appropriate situation in which to delay treatment.
People who are grieving are sad. But they may also have depression. They may even have already delayed treatment while caring for a loved one who was dying. Their depression needs to be treated.
Good riddance to the bereavement exclusion.
One red herring—bad doctoring:
Not everybody who presents with symptoms of depression need medication. Mild and moderate depressions respond just as well or better with non-medical interventions such as exercise or counseling. A doctor who hands a prescription to every depressed person is simply practicing bad medicine.
There are better ways to deal with this issue than denying care to those who need it. How about we ditch those AI programs on every doctor’s laptop that recommend treatment plans developed by pharmaceutical companies? How about we reimburse the time it takes for doctors to listen?
One misunderstanding:
Some people think of antidepressants as happy pills. They are not happy pills. They do not create feelings. They relieve the pall that prevents normal feelings, whatever they are. Happiness, yes, but also anger, interest, ambition, curiosity, hope, boredom. And yes, grief and sadness.
Good riddance
So the bereavement exclusion was indeed deleted from the DSM-5. It never was in the diagnostic manual used in other countries.
There is some brain science to back that decision. I’ll talk about the MRIs in a later post.
Your thoughts?