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Today in Your Health: bereavement. Traditionally, doctors have stayed away from diagnosing major depression in people who have just lost a loved one. In fact, the formal manual of the American Psychiatric Association warns doctors against it.
The idea has been that feelings of intense pain are normal, so they shouldn't be labeled a mental disorder. Now, the new manual coming out is making a controversial change, as NPR's Alix Spiegel reports.
ALIX SPIEGEL: In the winter of 1992, Theresa Smith took her 14-month-old daughter, Scarlett, to Arizona for an extended family visit. And one night, as they headed for bed, Theresa's mother made a declaration. She would watch the baby the next morning. Theresa should take the day for herself.��
Ms. THERESA SMITH: That morning, my mother was busy. She was doing some stuff with lawyers in New York. She was - had a restaurant or something, and she was irritated. And I said, Mom, I said, let me take Scarlett with me. I said, it's no problem. And then she stopped what she was doing and she goes, oh, no, no, no, no. We're going to be just fine, we're going to be just fine.
SPIEGEL: But they weren't just fine. Later that morning, Scarlett accidentally fell into a swimming pool. She drowned. Scarlett was Theresa's only child -literally, the center of her life. And so the months that followed were close to unbearable.�
Ms. SMITH: The nights. At one point, I wanted to smell Scarlett, and I looked -and I went around the apartment and I looked for her fingerprints, little spots where she spit up milk. I just looked for her everywhere.
SPIEGEL: During those months, Theresa says she cried every day. She considered suicide. And though she went back to graduate school, she found it hard to focus. She says she went to the cemetery every single night.
Ms. SMITH: I would bang my head against her headstone until my face was all bloody. And I would lay there, and I would cry all night. And it got to the point where one of my friends, her husband had a restaurant in town, and she would call. And she goes, when you close up, go to the cemetery and get Theresa, and take her home.
SPIEGEL: Today, Theresa is doing well - very well. And she says she has no regrets about the pain that she went through.
Ms. SMITH: It's a normal process of letting go of your child.
SPIEGEL: And do you think what you went through is normal?
Ms. SMITH: Yeah. Yeah. I mean, it was hard and it was crazy, but it's okay. It's grief. You've got to go through all of this.
SPIEGEL: But is what Theresa went through a normal part of the grieving process, or did the death of her child bring on a mental disorder - major depression - which could have been, perhaps should have been, aggressively treated?
Earlier this year, the American Psychiatric Association released a rough draft of its new diagnostic manual. And buried in its pages was a small but potentially potent change, a change that has implications for the way we think about and understand the emotion of pain.
What happened was that they removed from the manual something called the bereavement exclusion. Basically, the bereavement exclusion is a small, almost footnote at the bottom of the section that describes symptoms of major depression - a few short sentences which warn psychiatrists away from giving a diagnosis of major depressive disorder to people struggling with a recent death. The original idea was that pain in the wake of death is normal, so it shouldn't be seen as a disease.�
Ken Kendler is on the committee that decided to make this change, and he says it's not that the committee feels that everyone who has a loss should be immediately be diagnosed with depression. For Kendler, there is a clear, bright line between normal grief and clinical depression. Grief is okay, depression is not.�
So what, in Kendler's view, is grief?
Dr. KEN KENDLER (American Psychiatric Association): Typically, modest amounts of upset are fairly common, sometimes difficulty sleeping, crying over memories of the loved one.
SPIEGEL: People in grief, Kendler says, also often lack concentration. They lose sleep, lose appetite, lose energy. Now, I will tell you that these symptoms are also all symptoms of depression. So what's the difference between depression and grief, in Kendler's view? The symptoms of grief are much less severe, he says. And also, according to Kendler, in normal grief, acute pain doesn't last that long.
Dr. KENDLER: Usually for days at a time, not for weeks. For a few days of acute upset, and then a much longer period of the longing, the tearfulness. But typically sleep, appetite, energy, concentration come back to normal more quickly than that.
SPIEGEL: In fact, in the new manual, if symptoms like these persist for more than two weeks, the bereaved person will be considered to have major depression. Now, according to Kendler, this change will affect only a small number of people.
But Holly Prigerson, a researcher at Harvard who studies bereavement, says that while there's no good research on what percentage of people will meet the criteria for depression after a loss, it's clear that most experience depressive symptoms far beyond two weeks.
Dr. HOLLY PRIGERSON (Researcher, Harvard University): What we found is that when you follow people, their depression symptom levels actually increase over time, and peak at about six months post-loss.
SPIEGEL: And because grief and depression look so much alike, Prigerson says she worries that people who are suffering from normal grief will be told that they are sick when they are not, and encouraged to treat their symptoms when they don't need to - which is potentially a problem, Prigerson says, because of the following...
Dr. PRIGERSON: We don't know if the pain of normal grief actually helps people in some way to process their loss. What underlies a lot of this discussion is: Is it harmful to interrupt a normal grief process by medicating?
SPIEGEL: That is, does going through that intense emotional pain make you emotionally healthier later?
Ken Kendler says no.
Dr. KENDLER: Early on, there used to be the thought that there was this grief work, and that if you did not demonstrate lots of upset acutely after someone died, that later on there would be more distress. Research has shown clearly that that concept is false.
SPIEGEL: But Prigerson doesn't agree that the research is that clear.
Dr. PRIGERSON: I don't think we have the data to answer that. I think the jury's out.
SPIEGEL: I heard this from a number of people that we just don't know whether emotional pain helps people come to terms with death, or if you can do just fine without it.
But to Sid Zisook, one psychiatrist who's argued for removal of the bereavement exclusion, this academic question doesn't matter. The dangers of depression, he feels, are perfectly clear.
Dr. SID ZISOOK (Psychiatry, University of California, San Diego): I'd rather make the mistake of calling someone depressed who may not be depressed, than missing the diagnosis of depression, not treating it, and having that person kill themselves.
SPIEGEL: And just because pain after loss is normal, he says, doesn't mean you shouldn't treat it. Broken bones are painful, he points out.
Dr. ZISOOK: It's a normal consequence of breaking a bone. But it doesn't mean we don't treat the pain. We treat the pain vigorously.
SPIEGEL: But for some people, the real issue raised by the bereavement exclusion is really philosophical.
Allen Frances is a famous psychiatrist, a former editor of the Diagnostic and Statistical Manual. And he says more and more, psychiatry is medicalizing our experiences, turning emotions that are perfectly normal into something pathological.
Dr. ALLEN FRANCES (Psychiatrist): Over the course of time, we've become looser and looser in applying the term mental disorder to the expectable aches and pains and sufferings of everyday life.
SPIEGEL: From Allen's perspective, if you can't feel intense emotional pain in the wake of the death of your child without it being categorized as a mental disorder, then when in the human experience are you allowed to feel intense emotional pain for more than two weeks?
This perspective is also shared by Theresa Smith, the woman who lost her daughter close to 20 years ago.
Ms. SMITH: I grieved her just as hard as I loved her. I had to. It wouldn't have meant anything if I hadn't.
SPIEGEL: Alix Spiegel, NPR News, Washington.
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