Science & Technology

Good Grief vs. Bad Depression


Reviewing Gary Greenberg's book about depression in the October issue of Reason, I noted his criticism of the grief exception to the definition of "major depression" in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM):

Since everybody gets the blues, psychiatrists need to distinguish between normal sadness and pathological sadness, if only to preserve their own credibility as doctors treating illness. But such line drawing is unavoidably subjective. As Greenberg notes, the official definition of "major depression" excludes people who have experienced the death of a loved one within the previous two months. The American Psychiatric Association (APA) has decreed that 60 days of mourning is appropriate, while 61 is not. Up to the two-month line, you are experiencing normal grief; after that, you are sick.

Not only is the cutoff arbitrary, but so is the decision to count only death as a legitimate excuse for "a period of at least 2 weeks during which there is either depressed mood or a loss of interest or pleasure in nearly all activities." As Greenberg observes, "It's not clear why bereavement is the only exempt condition, why, for instance, misfortunes like betrayal by a lover or severe financial loss or political upheaval or serious illness—or for that matter a noncatastrophe, the slow accretion of life's difficulties or a loss of faith in one's government or simply existential despair kindled by an awareness of mortality—do not also spare people from the rolls of the diseased."

As Nick Sibilla mentioned earlier this afternoon, the psychiatrists working on the fifth edition of the DSM have proposed a solution to this problem: ditch the grief exception. The New York Times reports that critics of the change worry about "the potential for considerable false-positive diagnosis and unnecessary treatment of grief-stricken persons." Allen Frances, who oversaw the last revision of the DSM, warns that the new edition "will medicalize normality and that millions of people will get psychiatric labels unnecessarily." Jerome Wakefield, the NYU social work professor who wrote The Loss of Sadness, tells the Times:

An estimated 8 to 10 million people lose a loved one every year, and something like a third to a half of them suffer depressive symptoms for up to month afterward. This would pathologize them for behavior previously thought to be normal.

But isn't that what psychiatrists do? While the grief exception is arbitrary, so is the more general distinction between "normal" sadness and the mental illness called depression. How can judgments about the appropriateness of sadness possibly be objective and scientific? And since a mental disorder is whatever the APA says it is, I'm not sure it even makes sense to warn that a change in a disorder's definition will lead to "false-positive diagnosis."  

For more on this theme, see my 2011 essay. Kenneth Kendler, a member of the DSM-5 Mood Disorder Work Group, defends the new definition of depression here.