Medicalization of Grief

The APA’s DSM-5 removal of the bereavement exclusion made it easier for grieving individuals to be treated with psychotropic and other prescribed medications as early as two weeks after their loss. This issue continues to affect grieving individuals today. It opened the door to potentially misdiagnosing traumatically bereaved people with a mental disorder. Informed consent is imperative when working with vulnerable populations like the traumatically bereaved.

To find out more about the history of this issue, please read below.

(For immediate release December 4, 2012)

Dear MISS Foundation families, providers, and supporters,

We are saddened and disappointed by the recent announcement that the DSM-5 task force has finalized the decision to eliminate the bereavement exclusion from the Major Depressive Disorder diagnosis in the upcoming edition of the manual. This move will allow clinicians, including counselors, general physicians, social workers, and psychiatrists, to diagnose a major mental disorder in bereaved parents and other grieving individuals as early as two weeks following the death of a loved one should they meet the DSM-5’s criteria for depression. Importantly, many of you will recognize these criteria which include sadness, feelings of emptiness, crying, sleep and weight changes, guilt and regrets, and loss of interest or energy. Yet, all of these symptoms are quite common in grief, and particularly after the death of a baby or child which evokes enduring and intense reactions in parents.

This move has personal implications for the MISS Foundation. The DSM-5 change increases the likelihood that grief will be misdiagnosed as Major Depressive Disorder in the most vulnerable of all populations.1 The possibility exists that bereaved parents and other grievers will be mistakenly treated for a misdiagnosed mental disorder. Recent trends suggest that the most common form of treatment offered for this disorder is psychotropic medication.2-3 While some medications may be effective for some forms of depression,4 there is no sound evidence that they are effective for grief. Research shows that bereaved parents are already medicated earlier than can be justified by current evidence.5-6 We fear the DSM-5 change will exacerbate this trend and cause even more grieving individuals to be prescribed medication for symptoms which are actually a normative response, despite the lack of evidence to support this practice and a lack of information on how such medications may interfere with the grieving process.

The MISS Foundation has actively opposed this proposed change in DSM-5 and will continue to do so. You can read Dr. Joanne Cacciatore’s initial blog post which went viral in March of 2012 on this topic here.  The first open letter outlining our concerns sent to the American Psychiatric Association in March can be read here and another letter sent in April can be found here. Finally, in October the MISS Foundation issued a formal letter on behalf of the organization and can be viewed here. Finally, many links to research and articles about this issue can be found in this blog entry at the end.

We issue a caution to our families: We urge bereaved individuals to be informed about what this change could mean when seeking help from medical and mental health providers using DSM-5, scheduled to be published next year. Should you have concerns about the quality of medical/mental/emotional care you are being provided, please speak with experts who can help guide you. Get help somewhere, indeed.

Please be assured that many other parents are experiencing the same immense suffering and that you are not alone. Seek solace through skilled and highly trained providers who truly care for you and are willing to walk with you through your darkest times: providers who understand the death of a child as life’s worst tragedy and who will be truly present with and available to you. Seek solace through like others in support groups, online support and through your community.  Seek solace in spirituality and nature and books that help you to cope as you travel this overwhelming road. Seek solace through self-care and compassion. Seek solace through others who are unconditionally loving whether that be your partner, family, children, animals, or your faith based community. Seek solace through contemplative practice such as prayer, meditation, and quiet time and also through action in service and kindness toward others.

We issue an¬†ardent appeal¬†to providers: The bereaved are a vulnerable population. Please, be mindful and conservative in the issuance of diagnoses and medication, and educate yourselves in evidence-based practices as well as culturally influenced interventions. Take personal responsibility to learn what is truly normal, not pathological, after a traumatic death. The DSM-5 gives you much power and influence over the life of another. Please do not take this responsibility to ‚Äúdo no harm‚ÄĚ lightly.

Dr. Joanne Cacciatore, Founder Kara Thieleman, MSW, PhD

Karla Helbert, LPC, Facilitator

Dr. Melissa Flint, Clinical Psychologist

Kelli Montgomery, Executive Director

Dr. Trish Wonch Hill, Policy Analyst


Additional information and resources related to the issue of pathologizing grief
Bereaved parents and mental illness: The MISS Foundation mourns the loss of grief Psychiatry‚Äôs¬†Diagnostic and Statistical Manual‚Äės pathologizing of grief is but the latest installment of a lamentable tradition in Western civilization aptly chronicled by Philip Fisher in his book,¬†The Vehement¬†Passions(Princeton Univ. Press, 2002): ‚Äú[T]he twin ideas of Christianity‚Äôs eternal life and Stoicism‚Äôs nature have for two thousand years ‚Ķ pressed against the legitimacy of mourning and against the strong imagination of personal loss and mortality that grief sets in front of us, not as an idea, but as a profound physical and emotional experience ‚ÄĚ (p. 202). ¬†‚ÄúPain is not pathology,‚ÄĚ I wrote in my book,¬†Trauma and Human Existence¬†(Routledge, 2007, p. 10).¬†The traumatizing impact of human finiteness, as disclosed in the loss of a loved one, is not an illness from which one can or should recover. Read More (c) Dr. Robert Stolorow Robert D. Stolorow, Ph.D., Ph.D. is a Founding Faculty Member at the Institute of Contemporary Psychoanalysis, Los Angeles,¬†and at the Institute for the Psychoanalytic Study of Subjectivity, New York City. He is the author of World, Affectivity, Trauma: Heidegger and Post-Cartesian Psychoanalysis (Routledge, 2011) and Trauma and Human Existence: Autobiographical, Psychoanalytic, and Philosophical Reflections (Routledge, 2007) and coauthor of eight other books. He received his Ph.D. in Clinical Psychology from Harvard University in 1970 and his Ph.D. in Philosophy from the University of California at Riverside in 2007. Quick links related to the DSM-5 bereavement exclusion

  1. A fascinating BBC documentary, Medicalising Grief, featuring Drs. Jerome Wakefield and Joanne Cacciatore
  2. DSM5 and Ethical Relativism
  3. An Open Letter Regarding the DSM 5
  4. Bereavement and Snorting Seaweed
  5. Grief versus Depression: The American Psychiatric Association Responds
  6. DSM5, MDD, and Reliability

References

  1. Wakefield, J. C., & First, M. B. (2012). Validity of the bereavement exclusion to major depression: Does the empirical evidence support the proposal to eliminate the exclusion in DSM-5? World Psychiatry, 11(1), 3-10. doi:10.1016/j.wpsyc.2012.01.002
  2. Mojtabai, R., & Olfson, M. (2008). National trends in psychotherapy by office-based psychiatrists. Archives of General Psychiatry, 65(8), 962-970. doi:10.1001/archpsyc.65.8.962
  3. Olfson, M., & Marcus, S. C. (2010). National trends in outpatient psychotherapy. American Journal of Psychiatry, 167(2), 1456-1463. doi:10.1176/appi.ajp.2010.10040570
  4. Kirsch I., Moore, T. J., Scoboria, A., & Nicholls, S. S. (2002). The emperor’s new drugs: An analysis of antidepressant medication data submitted to the U.S. Food and Drug Administration. Prevention & Treatment, 5(1), 23a. doi:10.1037/1522-3736.5.1.523a
  5. Cacciatore, J., Lacasse, J. R., Lietz, C., & McPherson, J. (In press). A parent’s TEARS: Primary results from the Traumatic Experiences and Resiliency Study.
  6. Cacciatore, J., & Thieleman, K. (2012). Pharmacological treatment following traumatic bereavement: A case series. Journal of Loss and Trauma, 17(6), 557-579. doi:10.1080/15325024.2012.688699