As of May 2013, when the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is released, clinicians may diagnose an individual with a major depressive episode if they are experiencing grief. The current version states that it is not clinical depression unless two months have passed since the death of the loved one. The reason why the American Psychological Association (APA) decided to include grief under the umbrella of depression in the new DSM-V is because the DSM-IV does not exclude other losses such as divorce. The rationale is that if divorce can lead to a depressive episode, why not grief? And if people grieving can benefit from antidepressants, shouldn’t they have access to them?
This faulty logic is responsible for the increasing medicalization of universal human experiences and our society’s increasing reliance on psychotropic medications to cope with life. According to Dr. Sidney Zisook, Professor of Psychiatry at the University of California San Diego, “Acknowledging that bereavement can be a severe stressor that may trigger an MDE [major depressive episode] in a vulnerable person does not medicalize or pathologize grief! Rather, it prevents MDE from being overlooked or ignored and facilitates the possibility of appropriate treatment. Furthermore, removing the BE [bereavement exclusion] does not imply that grief should end in two months. Indeed, for many individuals, grief lasts for months, years or even a lifetime in its various manifestations, whether or not it is accompanied by MDE.”
The problem is that there is a significant difference between clinical depression and feeling depressed in response to grief, divorce, and/or some other traumatic event. Major depressive disorder is an illness that waxes and wanes across the lifespan. People with this disease can become depressed for no reason. They may, for example, start feeling fatigued, have trouble sleeping too much or not at all, and experience a change in appetite. These initial somatic symptoms can hinder their ability to function at school or work. They may not even be able to get out of bed and meet their basic hygienic needs. They suddenly find themselves in a depressed mood, in which things that they used to be passionate about don’t interest them at all. Nothing really triggers their depression, but anything remotely stressful in their life becomes amplified through a variety of cognitive distortions. They may view things in black and white, tell themselves what they should and should not do, compare out to others, focus on all the negative and filter out the positive, assume what others are thinking, and hopelessly catastrophize about the future. Their negative self talk, lack of ability to derive pleasure in life, low energy, and decreased functioning may lead them to contemplate suicide and in the worst case scenario, actually follow through with the plan. These random depressed episodes, which have no stressor in origin is what differentiates people with clinical depression from the rest of the population.
Major depressive episodes can also be triggered by stressful life events, like the loss of a loved one. However, the experience of bereavement itself is a normal human experience that can mimic a lot of the symptoms associated with major depressive disorder. It becomes pathological when the process is disabling and prolonged for several months and sometimes years. By ruling out the bereavement exclusion from the clinical criteria of depression in the DSM-V, people experiencing normal grief can be misdiagnosed with depression. They may currently be feeling depressed, but they don’t necessarily have the chronic disease of depression. Grouping these two types of experiences is dangerous, primarily because it implies that both need to be medicated.
Psychiatry is still in its infancy. We don’t know exactly what causes mental illness. We are told that individuals with mental illness have a “chemical imbalance” in their brain; this is both vague and misleading. The business of psychiatry has deceived us into believing that the best way to correct this chemical imbalance is to take psychotropic medication. People fail to acknowledge that these are mind altering substances with potentially harmful side effects. Psychiatric medication combined with psychotherapy has become the first line of treatment. Any other alternatives are dismissed as illegitimate. This ideology is backwards.
Mental illness needs to be treated like a skin rash. Imagine coming into contact with poison ivy. Your initial reaction would be to cleanse the exposed area with rubbing alcohol, soap, and water. If it itches, you may want to try hot and warm water compresses. You know that the rash will go away on its own, but if it really itches and makes you uncomfortable, you might want to try an over the counter antihistamine like Benadryl. If that doesn’t relieve you of your symptoms, you may want to consult a doctor to get a prescription for a topical steroid cream. If you have an autoimmune condition, your rash may become so severe that you need an oral steroid like Prednisone to get rid of the rash. The analogy is that we are constantly coming into contact with stressors (poison ivy), which has the potential to trigger a depressive episode (skin rash). You can begin dealing with these feelings by doing something self-soothing and relaxing. You know that these feelings will inevitably pass. Proper diet and moderate exercise can help stabilize your mood, just as home remedies can help heal the rash. There are no side effects, just as there are no side effects for putting warm water compresses on your skin. If your depression continues for several weeks and negatively affects your ability to function, you may want to meet with a therapist. Hopefully, you will be able to work through your problems and move on with your life. If a combination of proper diet, exercise, and psychotherapy doesn’t help, you may want to see a psychiatrist and get screened for clinical depression. A clinically depressed person is similar to someone with an autoimmune condition, in that they are both hypersensitive to the external stimuli and need medication.
Likewise, psychiatric medication should only be prescribed in cases where a patient is presenting true clinical depression, the kind that is both chronic and disabling. It should never be prescribed for people experiencing situational depression in response to traumatic life events such as death of a loved one, sudden job loss, divorce, miscarriage, etc. It’s not worth the side effects, which can sometimes counterproductively increase feelings of anxiety and depression. Antidepressants can also induce insomnia, restlessness, drowsiness, fatigue, weight gain, decreased libido, headaches, tremors, and dizziness. Besides, medicine doesn’t solve problems. These individuals would best benefit from therapy and alternative forms of emotional healing. The issue then becomes how to get insurance to cover psychotherapy for people without a diagnosable mental disorder. Rather than medicalizing grief by changing the DSM, we need to bill insurance companies for the psychosocial stressors listed on Axis IV. This will allow people experiencing grief to get the type of treatment they need without labeling them as mentally ill and forcing them to take medication. It is important that we extend psychotherapeutic resources to normally mentally healthy individuals experiencing temporary situational depression because they, like people with clinical depression, are at risk of suicide.
There are many cases of completed suicides by people with no history of mental illness. Some of them were undiagnosed, others were never mentally ill. Suicide is not always rooted in pathology. For example, someone who recently lost a loved one may be experiencing suicidal ideations because they want to be reunited with their loved one in the afterlife. It is also understandable for elderly individuals with a terminal illness to want to prematurely end their life. In fact, the elderly are at the highest risk for suicide.
Any individual with suicidal ideations must be taken seriously and psychiatric hospitalization may be required to keep them safe until they stabilize. Being hospitalized doesn’t necessarily mean that they have a mental illness, which also means that they shouldn’t be medicated. However, this is not how it works within the social institution of psychiatry. Anyone admitted to an inpatient psychiatric facility is automatically diagnosed with a mental illness and routinely placed on medication. Ethically, suicidal individuals with no history of mental illness should not be placed on potentially harmful psychotropic medication unless their symptoms persist for months. If that is the case, they may already have a biological predisposition to major depressive disorder, such that the stressful life event triggered the onset of the illness. This population, as I argued earlier, needs both medication and therapy. Anyone’s symptoms that go away after a few weeks of the stressful life event are probably not mentally ill, and thus, would not benefit from psychotropic medication. They may appear to be getting better on the medication, but that is most likely because depression goes away with time. The medication may also appear to be preventing future depressive episodes because they don’t have major depressive disorder to begin with. Ultimately, many people have been falsely labeled as “mentally ill” and are taking psychotropic medication for no reason and are unnecessarily suffering the side effects. They may also be experiencing the harsh stigma associated with mental illness. Getting rid of the bereavement exclusion in the DSM-5 is going to further perpetuate this. Diagnosing a major depressive episode should solely be based on the severity and duration of the symptoms.
Another danger associated with diagnosing people with mental illnesses that they don’t really have is that it falsifies prevalence rates, which has serious implications for understanding mental illness in society. According to the National Institute of Mental Health website, 9.5% of the United States population age 18 or older in a given year, have a mood disorder. What does that even mean? Are 1 out of 10 adults so depressed they can barely get out of bed and take care of their basic hygienic needs for a few weeks or months out of the year? This statistic can be very offensive to a person who truly suffers from major depressive disorder, especially individuals who are so handicapped by their mental illness that they need to be on Social Security Disability. Everybody has problems, but some people have real problems. The goal is not to minimize someone’s experience, but to keep these definitions distinct. Feeling depressed and having depression cannot be used interchangeably.
Our society relies far too heavily on the DSM to legitimize our emotional experiences. We have been brainwashed into believing that if our feelings and behaviors aren’t listed in the DSM, then our problem doesn’t exist. If our feelings and behaviors are listed in the DSM, then there is something fundamentally wrong with us and we need to be fixed. The truth is that all of our feelings, no matter where they fall on the continuum, are valid. However, we cannot continue to blur the boundaries between feeling depressed and suffering from the disease of depression. There is a huge difference between these two conditions: one being situational and temporary, the other being a chronic illness that will need to be managed throughout the life course. While both are very serious and are deserving of mental health treatment, particularly when suicidal ideations are present, both do not require medication. Perhaps in the mist of a crisis, medication may be helpful, i.e. a benzodiazepine to calm someone down, but in the long-term, there is no benefit of taking antidepressants if you are experiencing a transient depressive episode.
However, we are living in a consumer age where antidepressants are constantly being advertised in the media. We have been taught that numbing our emotions with psychoactive drugs is the most efficient way to cope with distress. Just like our fast foods and speedy highways, we are always looking for a quick fix. We live in a fast paced world and don’t have time to deal with our issues. Surely, a pill will do the trick and we can go back to our busy lifestyle. Access to these drugs is very easy. All you have to do is go to a psychiatrist and present yourself as depressed during a sixty-minute psychological evaluation. Afterwards, you will be diagnosed with major depressive disorder and receive a prescription for an antidepressant that you can fill at the local pharmacy. Nobody ever suggests that maybe all you need is some psychotherapy to help you get through your problems.
Hopefully one day we will be able to medically test for emotional and behavioral disorders, similarly to how we can test for neurological disorders. But for now, we have the DSM, which is a highly subjective and far from scientific approach to diagnosing psychiatric conditions. We must approach this diagnostic tool with a great deal of skepticism and be mindful of the hidden forces behind its publication, such as the pharmaceutical industry. Their primary objective is to expand diagnostic categories as much as possible so they have more customers to take their pills. They are aggressive enough to manipulate research and deceive well-meaning mental health professionals into believing that expanding the elasticity of diagnostic categories will help more people in distress. This would not even be an issue if insurance companies would just cover treatment for psychosocial stressors listed on Axis IV, as I proposed earlier. Instead, we are forced to pathologize normal human experiences so individuals in the slightest bit of distress can access mental healthcare. When trying to understand how we’ve arrived at a point where grief has become a mental illness, we must keep in mind that psychiatry is a business.