Lancet, 2012 Editorial: Living with grief

[Gem]

Living with grief

 

The Lancet

 

The Lancet, Volume 379, Issue 9816, Page 589, 18 February 2012

 

http://tinyurl.com/7cutghd http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60248-7

 

When should grief be classified as a mental illness? More often than is current practice, proposes the American Psychiatric Association in its forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Previous DSM editions have highlighted the need to consider, and usually exclude, bereavement before diagnosis of a major depressive disorder. In the draft version of DSM-5, however, there is no such exclusion for bereavement, which means that feelings of deep sadness, loss, sleeplessness, crying, inability to concentrate, tiredness, and no appetite, which continue for more than 2 weeks after the death of a loved one, could be diagnosed as depression, rather than as a normal grief reaction.

 

The death of a loved one can lead to a profound, and long-lasting, grieving process, which is movingly described in an essay by Arthur Kleinman in this week's Art of Medicine section. After his wife died, it took 6 months before Kleinman's feelings of grief became “less acute” in his own words, and almost a year on, he feels “sadness at times” and harbours “the sense that a part of me is gone forever…I am still caring for our memories. Is there anything wrong (or pathological) with that?”

 

Most people's experiences of grief would align with Kleinman's. It is often not until 6 months, or the first anniversary of the death, that grieving can move into a less intense phase. Grief is an individual response to bereavement, which is shaped by the strength of relationship with the person who has died, being male or female, religious belief, societal expectation, and cultural context, among other factors. Malcolm Potts, in an essay in this journal in 1994, after the death of his wife, said: “Grief is an astonishing emotion. It is the tally half of love and it has to be….Anguish, body-shaking weeping, grief: a biological behaviour that had been latent and unused in my brain…I would not and could not forgo it. Grief has to be.” 18 years after his stillborn daughter was born, Steven Guy said: “I have moved on; I can talk about the day she died and not cry, sometimes…She has changed me from the shy insecure person I was then to the openly emotional, caring, supportive, and strong man I am now.”

 

Medicalising grief, so that treatment is legitimised routinely with antidepressants, for example, is not only dangerously simplistic, but also flawed. The evidence base for treating recently bereaved people with standard antidepressant regimens is absent. In many people, grief may be a necessary response to bereavement that should not be suppressed or eliminated. For some, though, whose grief becomes pathological (sometimes known as complicated or prolonged), or who develop depression, treatment with drugs or, sometimes more effective psychological interventions such as guided mourning, may be needed. WHO's International Classification of Diseases, currently under revision as ICD-11, is debating a proposal to include “prolonged grief disorder”, but it will be another 18 months before that definition will be clear. Bereavement is associated with adverse health outcomes, both physical and mental, but interventions are best targeted at those at highest risk of developing a disorder or those who develop complicated grief or depression, rather than for all.

 

Building a life without the loved person who died cannot be expected to be quick, easy, or straightforward. Life cannot, nor should not, continue as normal. In a sense, a new life has to be created, and lived with. After the loss of someone with whom life has been lived and loved, nothing can be the same again. In her memoir to her husband, Nothing was the same, Kay Redfield Jamison, comments: “There is a sanity to grief” in contrast to her own experience of bipolar disorder.

 

In Kleinman's words, “My grief, like that of millions of others, signalled the loss of something truly vital in my life. This pain was part of the remembering and maybe also the remaking. It punctuated the end of a time and a form of living, and marked the transition to a new time and a different way of living.”

 

Grief is not an illness; it is more usefully thought of as part of being human and a normal response to death of a loved one. Putting a timeframe on grief is inappropriate—DSM-5 and ICD-11 please take note. Occasionally, prolonged grief disorder or depression develops, which may need treatment, but most people who experience the death of someone they love do not need treatment by a psychiatrist or indeed by any doctor. For those who are grieving, doctors would do better to offer time, compassion, remembrance, and empathy, than pills.

Edited February 18, 2012 by Altostrata
edited title, added link

[Altostrata]

Interesting, the Lancet criticizes the DSM-5.

[Jemima]

Living with grief

 

The Lancet

 

The Lancet, Volume 379, Issue 9816, Page 589, 18 February 2012

 

http://tinyurl.com/7cutghd http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60248-7

 

When should grief be classified as a mental illness? More often than is current practice, proposes the American Psychiatric Association in its forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Previous DSM editions have highlighted the need to consider, and usually exclude, bereavement before diagnosis of a major depressive disorder. In the draft version of DSM-5, however, there is no such exclusion for bereavement, which means that feelings of deep sadness, loss, sleeplessness, crying, inability to concentrate, tiredness, and no appetite, which continue for more than 2 weeks after the death of a loved one, could be diagnosed as depression, rather than as a normal grief reaction.

 

 

Oh dear God, this is so absurd. Back when I was a psychotherapist, in the late sixties and the seventies, I thought the DSM was scary, but it's getting even more so now. Shrinks somehow manage to classify nearly all normal behavior as "mental illness", which is probably a total myth in itself except for cases of physical brain damage. What a racket!!!

 

I think a normal grieving period is more like two years, not two months, and it may be even longer if a person is struck with several devastating events in a short period of time. Bravo for "The Lancet"!!!

[Jemima]

Oops. I meant two weeks, but even two months is not long enough to allow for normal grieving.

[Altostrata]

I agree, the DSM-5's attitude towards grief (and you should read the justifications for this) demonstrate that biological psychiatry has no clue about human emotions.

 

A lot of organizations are up in arms about this. Jemima, have you signed the DSM-5 petition http://www.ipetitions.com/petition/dsm5/ ?

[Gem]

I agree. People need as long as it takes for grieving.

 

I think the labelling of normal human emotion and behaviour as ‘illness’ is totally abhorrent.

 

Who is to say what is normal and what is not anyway. Certainly not those who couldn’t give a rat’s arse about what damage these drugs are doing.

[Nikki]

I am experiencing some grief right now and I am afraid of it.

 

My Mom is 88 years old. This week she had a CT Scan and a nodule was discovered in the lung.

She needs another Scan with contrast this time. We talk openly about her passing and I always tell her how much I love her and will miss her.

 

When I thnk about her not being around I become terrified by what will be the absence of my friend/mother and the thoughts creep up about the grief, anguish, anxiety and fear of a meltdown.

 

She assures me she felt the same way about her mother and that it will pass with time.

 

I am choked up typing this. It's been with me all week. I did talk to my brother and daughter about it, but I dont think they understand the deep fear I have inside.

 

When my Dad died I knew I still had my Mother. How do people move on? The article pointed out that the pain is there for a reason and it takes time to heal. Honestly, this may sound nutty, but my fear is that I won't be able to deal with the pain.

 

Been in an emotional roller-coaster for a few years now and have kinda reached my saturation point with myself. Basically, I am a broken record of fear, anxiety, stress and worry.

 

Hugs

[fefesmom]

Nikki.

I don't know, but hope, if this will be of any help/support/understanding to you but...my depression started in full after my mother died in 1996. I was put on ads less than a year later because I cried a lot. I was able to work and carry on life as usual. So I got numbed out until I went off cold turkey six months ago. My father had died 17 years before my mother died and although his death was hard to deal with I, too, felt at least I had her and after he died she and I became closer. I remember feeling totally alone after she died and no one seemed to "get" it, including some therapists. I have that same aloneness feeling now. And it isn't an aloneness that can be "fixed" by meeting new people etc.

Oh, I ache for you and send care and love even though i don't know you.

This site is a miracle. I trust it will be so for you, too.

[meistersinger]

Nikki.

I don't know, but hope, if this will be of any help/support/understanding to you but...my depression started in full after my mother died in 1996. I was put on ads less than a year later because I cried a lot. I was able to work and carry on life as usual. So I got numbed out until I went off cold turkey six months ago. My father had died 17 years before my mother died and although his death was hard to deal with I, too, felt at least I had her and after he died she and I became closer. I remember feeling totally alone after she died and no one seemed to "get" it, including some therapists. I have that same aloneness feeling now. And it isn't an aloneness that can be "fixed" by meeting new people etc.

Oh, I ache for you and send care and love even though i don't know you.

This site is a miracle. I trust it will be so for you, too.

 

I know the feeling all too well. I just lost my mother this past november. I still have feelings of guilt, being responsible for her death, due to me losing my job delivering pizza (part time) for a moving violation and now being blackballed by the major chains. Yes, I know she was in declining health, and I was no way responsible, BUT DAMNIT, I STILL HURT!!! I started on Vybriid before she died, so I wonder if Vybriid also is contributing to this problem?