Is Grief an Illness? The Debate Heats Up

Psychiatric experts torn on whether bereavement should be included in new diagnostic manual

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By Alan Mozes
HealthDay Reporter

THURSDAY, Feb. 16 (HealthDay News) -- The loss of a loved one can trigger deep emotional turmoil, but is the grief that follows a normal part of being human or is it a form of mental illness in need of diagnosis and treatment?

That's the gist of a major debate now unfolding in the world of psychiatry, as the American Psychiatric Association (APA) prepares to issue the fifth edition of its seminal reference guide to mental disease, the Diagnostic and Statistical Manual of Mental Disorders (DSM).

The issue: For the first time, the manual -- a touchstone for mental health professionals across the United States -- may not exclude the concept of "bereavement" from the constellation of behaviors and experiences that it deems worthy of consideration when clinicians set out to diagnose a major depressive disorder.

What does this mean? That feelings or outbursts accompanying the passing of a family member or close friend -- such as crying, insomnia, fatigue, confusion and profound sadness -- may now be viewed as a treatable illness rather than as a normal reaction to life's most shattering moments.

Needless to say, not everyone agrees with this shift in thinking.

"To me, grief is a normal condition, not to be tagged with a diagnostic code and to be treated," stressed Dr. T. Byram Karasu, chairman of psychiatry and behavioral sciences at Albert Einstein College of Medicine and psychiatrist-in-chief at Montefiore Medical Center in New York City. "Everyone loses someone in their lives at some point. So, this would be classifying everyone at some point. No one would be immune to this."

"And that does not make sense, because grief is a normal and very healthy behavior," said Karasu, who also chairs the APA's National Task Force on the treatment of depression. "One has to feel joy as well as pain and depression, otherwise life is not worth living. And one should not interrupt the grieving by medication or psychotherapy. You have to feel the loss, and only by feeling the loss and recovering from it will the person become a better person. Interrupted grief will remain unfinished business."

Karasu's stance is in line with those expressed by the editorial board of the British medical journal The Lancet, which lays out its opposition to the new clinical approach in its Feb. 18 issue.

"Grief is not an illness," the journal's editors argue, noting that a diagnostic change in the APA's forthcoming manual would empower clinicians to interpret any post-loss despair that endures beyond a two-week window as a troubling sign of sickness rather than a standard sign of coping.

The Lancet team suggests that, instead, an intense but normal bout of grief can last six months to a year, depending on the very individualized nature of the particular relationship that has been severed by death.

"Medicalising grief, so that treatment is legitimized routinely with antidepressants, for example, is not only dangerously simplistic, but also flawed," the authors noted.

They acknowledged, however, that sometimes grief can morph into something much more complicated, longer lasting and "pathological." In such instances, true clinical depression may ensue along the lines of a so-called "prolonged grief disorder," a potentially new designation now under consideration by the World Health Organization. And such patients, the board agreed, might stand to benefit from some form of mental health intervention.

The concern over exactly when normal grief becomes a condition that perhaps requires treatment is what's driving the notion of inclusion in the DSM, said University of California, San Diego, psychiatry professor Dr. Sidney Zisook.

"It is well recognized that the death of a loved one, just like any other serious stressor, [such as the] loss of a job, diagnosis of a fatal illness, divorce can trigger a clinical depression," he said. "The ensuing depressive syndromes are no less severe or debilitating when brought on by bereavement as they are after any other life event or, indeed, when the depression seems to occur out of the blue."