Rosenblum: Good grief! Get over a death in 2 months? They can't be serious

  • Article by: GAIL ROSENBLUM , Star Tribune
  • Updated: December 12, 2012 - 11:09 PM

I just finished reading the American Psychiatric Association's new recommendations regarding the wrenching universal experience called grief.

I'm pretty sure they have a misprint.

Two months? They meant two years, right?

But, no. With a disappointing change in the APA's Diagnostic and Statistical Manual (DSM-5), even raw, early-stage bereavement now can be viewed as a depressive disorder, as in, "It's been two months since she/he died and you're not over it yet?"

Changes to the previous manual, DSM-4, were approved around many mental health issues in early December, with the dropping of "Asperger's disorder" getting tons of media attention. These are the first revisions since 1994.

On the grief front, I'm going to assume the authors are very lucky people who never have lost a loved one.

For decades, few medical professionals worried about a patient expressing sadness, tearfulness or insomnia in the weeks or months after the death of a family member or close friend. In fact, a person not experiencing such symptoms would likely raise eyebrows.

In support of that normal passage, the two previous diagnostic manuals, spanning 40 years, included a "bereavement exclusion" to a depression diagnosis. That allowed doctors to say, "Well, of course you want to cry every time you hear that song/eat that flavor of ice cream/look at your young children. You're not depressed. You're human."

Only if the patient was unable to begin climbing back to a new state of normalcy by the half-year point might they start talking about a more aggressive strategy. That could include anti-depressants, psychotherapy, a support group or a combination.

The new manual removes the bereavement exclusion. Supporters in the psychiatric community say it's hard to know when "normal" grief related to loss will plunge into a full-blown depression. Why wait?

Besides, without a diagnosis -- without bringing out words like "disorder" -- insurance companies likely won't cover care or medication. I'm guessing pharmaceutical companies are delighted with the shift.

Richard Friedman is not. The professor of clinical psychiatry at Weill Cornell Medical College in New York expressed his concern about the potential change back in May in a letter published in the New England Journal of Medicine.

While acknowledging that "it can be challenging for many practitioners to tell the difference between acute grief and depression," removal of the bereavement exclusion, Friedman wrote, "would encourage clinicians to diagnose major depression in persons with normal bereavement after only two weeks of mild depressive symptoms."

That, said Friedman, who specializes in anxiety and mood disorders, would lead to "unnecessary treatment with antidepressants and anti-psychotics, both of which are increasingly used to treat depression and anxiety." He confirmed that concern with me in a phone call Wednesday.

Gary Schoener, a director at the Minneapolis Walk-in Counseling Center since 1969, isn't as certain.

"Grief is normal, not pathological," Schoener agreed. "It doesn't feel good and you'll need support, but that doesn't make it a disorder."

On the other hand, grief can become a depression, "which you may not be able to come out of on your own," he said. "The challenge for us, whether we're shrinks or average people, is to think in terms of, 'When has something gone over the edge? When can medications be helpful?' "

When Schoener began practicing, there was little talk about grief, or about whether it was a normal passage or a concern requiring medical intervention.

The hospice movement of the 1970s changed that, particularly thanks to the seminal work of psychiatrist Elisabeth Kübler-Ross, who developed the now-famous five stages of grief.

Gayle Sherman Crandell, a grief specialist and co-founder of Crocus Hill Counseling Center in St. Paul, was strongly influenced by Kübler-Ross' work, which, she said, got people talking about death, grief and healing.

But even today, grieving remains a deeply personal, and frequently messy, journey that we don't really get over.

"It's not a wrong we need to right," Sherman Crandell said. "It's an experience from which we draw meaning."

Why wait?

Because most of us do find our way through, if given ample room to cry, a compassionate ear willing to listen to our stories over and over again, and a pass from well-meaning friends -- and professionals -- looking at their watches.

gail.rosenblum@startribune.com 612-673-7350

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