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Can Grief be a Mental Illness?
With New Diagnostic Changes, Maybe

BY TIM TOWNSEND                                                                                    ©2013 St. Louis Post-Dispatch

Each year 90,000 parents in the U.S. confront the profound suffering that follows the death of a child or adolescent.

Some of those rely on faith to help them through their grief. Others look to psychiatrists, who offer therapy or prescribe antidepressants to help ease their patients’ pain.

On May 18, in a move that could add to the tension between religion and science, the American Psychiatric Association changed a controversial diagnosis regarding how grief relates to mental health.

The change “will affect every single person in the country, because at some point we’re all going to be bereaved,” said Joanne Cacciatore, founder of the Center for Loss and Trauma in Phoenix and a professor of social work at Arizona State University.

At issue are questions as fundamental as how long we grieve, what clinical label we assign to sadness, and when grief transforms into mental illness.

The modification also rekindles long-standing debates about whether spirituality or medicine offers the best pathway out of bereavement.

The debate comes down to a small edit to the Diagnostic and Statistical Manual of Mental Disorders, a guidebook that is considered psychiatry’s diagnostic bible.

After 14 years of work, the fifth edition of the book — called DSM-5— was unveiled in San Francisco at the annual meeting of the 36,000-member American Psychiatric Association.

Changes in each revision are important because most insurance companies require a DSM diagnosis before they reimburse doctors. The manual is also seen as the definitive psychiatric reference by other professions such as law, government and journalism.

Psychiatry historically has refrained from calling normal grief a mental disorder. Since the last DSM was published in 1994, the guideline has been that when symptoms—sadness, distress, insomnia, trouble concentrating, lack of appetite—begin within two months of a loved one’s death, but do not persist beyond those two months, psychiatrists should not diagnose “major depressive disorder.” In earlier decades, psychiatrists waited a year before such a diagnosis.

The revision narrows that window to two weeks. So a person who has five of nine symptoms that define depression—regardless of the reason behind those symptoms—could be diagnosed as mentally ill.

That change could give psychiatrists earlier access to grieving patients, critics say, heightening a perception that medical responses to grief are encroaching on turf traditionally held by faith.

“It’s in the realm of the spiritual that we learn to accept the unanswerable questions,” Cacciatore said. “People can get help without being labeled mentally ill. That’s what churches are for, that’s what community is for, that’s what spiritual leaders are for.”

The shrinking window for grief has stoked what psychotherapist Gary Greenberg describes as an insurgency against the DSM, fueled, in part, by accusations that the changes would help funnel money to manufacturers of psychotropic drugs.

But supporters of the revision to the DSM say the change has been misunderstood. Narrowing the grief window, they say, is about improving psychiatry’s response to major depression. And the change does not interfere with the role of faith-based supports.

“There is nothing in the recognition of major depression that precludes the patient’s receiving love and comfort from friends, family and clergy,” Ronald Pies, a professor of psychiatry at SUNY Upstate Medical University, said in an email.


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