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Exploring depression
Exploring depression

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Medicalising grief?

The DSM was first published in 1952 in the United States as a guide to help mental health professionals communicate using a common diagnostic language. As understanding of mental health conditions has evolved, the manual has been periodically updated to remove elements that are no longer considered valid, adding newly defined conditions or revising existing criteria to reflect contemporary thinking. Prior to the publication of DSM-5 in 2013, concern had been raised in an open petition at the possibility that the proposed revisions to certain criteria would ‘medicalise’ patterns of behaviour and mood that would otherwise be considered within the normal spectrum for human experience (Frances, 2012, 2013; Kamens, Elkins and Robbins, 2017).

These concerns were echoed by the British Psychological Society in their statement (BPS, 2011) supporting the open petition to the DSM Taskforce by the Society for Humanistic Psychology (see Kamens, Elkins and Robbins, 2017) in which they made clear the view that ‘a major concern …. is that the proposed revisions include lowering diagnostic thresholds across a range of disorders. It is feared that this could lead to medical explanations being applied to normal experiences, and also to the unnecessary use of potentially harmful interventions’, and further that ‘we share concerns expressed in the open letter about the inconsistency of the proposed changes and their limited empirical basis’ (BPS, 2011).

The petition specifically questioned ‘proposed changes to the definition of mental disorder that deemphasize sociocultural variation while placing more emphasis on biological theory. In light of growing empirical evidence that neurobiology does not fully account for the emergence of mental distress’ (Kamens, Elkins and Robbins, 2017). Expanding on this concern further, the statement clarified that ‘advances in neuroscience, genetics and psychophysiology have greatly enhanced our understanding of psychological distress’; however, ‘not one biological marker ‘biomarker’ can reliably substantiate a DSM diagnostic category. In addition, empirical studies of etiology are often inconclusive, at best pointing to a diathesis-stress model with multiple (and multifactorial) determinants and correlates’. And thus, ‘in the absence of compelling evidence, we are concerned that these reconceptualizations of mental disorder as primarily medical phenomena may have scientific, socioeconomic, and forensic consequences’, that ‘psychopathology, unlike medical pathology, cannot be reduced to pathognomonic physiological signs or even multiple biomarkers’, that ‘hypothesizing a medical explanation for these symptoms will resolve the philosophical problem of Cartesian dualism inherent in the concept of ‘mental illness’, and that clinicians would be required ‘to draw on subjective etiological theory to make a judgment about the cause of presenting problems’ (Kamens, Elkins and Robbins, 2017).

Concerns around the ‘bereavement exclusion’ in DSM-5

One of the main concerns voiced by the petition, and by the former Chair of the DSM-IV Taskforce, Professor Allen J. Frances, was around the proposed removal of the ‘bereavement exclusion’ in the diagnosis of Major Depressive Disorder, which in the previous version was considered an important measure that prevented the ‘pathologization of grief, a normal life process’ (Frances 2012, 2013; Kamens, Elkins and Robbins, 2017). This has perhaps been one of the most contentious changes to the DSM. At the heart of the argument opposing the change, is the view that grief is a normal, albeit difficult and upsetting, part of human experience that should not require a formal diagnosis as a ‘psychiatric illness’ requiring treatment using medications such as antidepressants, and that its ‘inclusion’ is likely to lead to overdiagnosing or misdiagnosing of depressive illness.

Professor Frances wrote in 2013:

It is not at all pathological to have symptoms that closely resemble mild depression during bereavement. The Bereavement Exclusion is absolutely necessary to protect against the false positive over diagnosis of depression…two critical features of clinical depression are that it predicts a higher likelihood of later recurrence of new depressive episodes and a highly elevated rate of suicide attempts…there was no previous problem in DSM IV that needed fixing. Grievers who have severe and urgent symptoms−suicide risk, psychotic symptoms, severe agitation, inability to function−have always qualified for the diagnosis of Major Depressive Disorder; while those having typical symptoms of grief were appropriately regarded as having a normal, human reaction to a grave loss…Grief is a normal and inescapable part of the human condition, not to be confused with psychiatric illness.

(Frances, 2013)

Professor Frances summarised his concerns around the wider changes proposed in DSM-5, in an online post in 'Psychology Today' in December 2012, noting that:

People with real psychiatric problems that can be reliably diagnosed and effectively treated are already badly shortchanged. DSM5 will make this worse by diverting attention and scarce resource away from the really ill and toward people with the everyday problems of life who will be harmed, not helped, when they are mislabeled as mentally ill.

(Frances, 2012)

But there have been arguments to counter the above view as well, noting for example, that for many people with a mental health problem, receiving a diagnosis can be helpful – it can give people access to other support and services, including benefits (NHS Choices, 2013).

Views amongst psychiatrists have also been mixed (Nemeroff et al., 2013). Carmine Pariante, Professor of Biological Psychiatry at King’s College London noted that:

… removal of [the] bereavement exclusion will allow individuals who have been clinically depressed for less than 2 months after the loss of a loved one to be diagnosed with Major Depression…Does this mean that hordes of individuals who have just lost their partner or their parent will be started on antidepressants? Obviously not: first, because individuals will still need to fulfill the diagnostic criteria for depression, including the impairment in important areas of functioning such as their social or professional life; and second – and crucially – because no clinically competent doctor would do so…clinical competency and personalized decisions are, as always, key to clinical management, and diagnostic textbooks will not make good doctors take bad decisions.

(cited in Nemeroff et al., 2013)

On the other hand, Florian Seemüller, Consultant Psychiatrist at Ludwig-Maximillians-University in Munich noted that:

… in order to improve test-retest reliability and reduce the number of false positives, tightening of the diagnostic criteria for such problem diagnoses would have been desirable; however, with the elimination of the major depression bereavement exclusion in the DSM-5, the diagnostic boundaries have again been widened. Thus a major depressive episode can be diagnosed if a person grieves for a loved one for more than two weeks…clinical research further suggests that the risk for recurrent depression in people experiencing severe grief is not different from that of healthy controls. Although some individuals, especially elderly people with complicated grief, may benefit from this change, possibly by earlier receipt of intensive treatment after having lost a loved one, millions of other people might be unnecessarily labeled as having an illness, and consequently receive treatment that they do no need.

(cited in Nemeroff et al., 2013)

A further rationale for the ‘bereavement exclusion’ was provided by the American Psychiatric Association in a document highlighting changes from the previous version (APA, 2013b).

Although the DSM represents a useful guide for defining and communicating about mental health, and can be used to support clinical decision-making, limitations should also be considered. Issues such as the one discussed here represent a legitimate area of debate and underscore the challenges of diagnosis, treatment and care for people affected by mental health conditions.