Pathologising sadness

Imagine losing the one person you love the most. In the long days, weeks and months that follow, you ride a rollercoaster of painful feelings and emotions. You are devastated and lose interest in everything. You can’t focus or concentrate. The mere thought of food makes you sick. You suffer from insomnia. If you do manage to sleep, you still wake up feeling exhausted.

Seeing how much you’re suffering, a kind and well-meaning friend finally persuades you to visit a doctor …

What happens next hinges on a review of the criteria for depression that is currently underway by the American Psychiatric Association, which is wrapping up work on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or D.S.M. This tome of diseases is the bible for the field, shaping treatment decisions, and its revisions will reverberate through people’s lives for years to come.

As the manual is finalised, outside experts such as Dr Allen Frances from Duke University in the US, speaking recently on the ABC Radio National Breakfast program, are scrutinising its finer points, and finding some deeply worrying, in particular, a proposal to eliminate the “bereavement exclusion” from the current definition of depression.

Frances explains that this would allow the diagnosis of Major Depressive Disorder after a mere two weeks of normal grieving symptoms, with unfortunate consequences. “The way the world works now, too often that will lead to a doctor giving you a pill. This is harmful, unnecessary and it substitutes a superficial medical ritual for the traditional ways that people have always dealt with the loss of someone they love.”

Frances suspects that behind the proposal is a concern for consistency. If you experience other types of loss, for example, go through a divorce, or lose your job, and your grieving symptoms persist for longer than two weeks, according to D.S.M. 4, you have a major depression.

So the people agitating for this new definition probably mean well, he suggests, because they’re worried about people who have genuinely been bitten by the black dog being missed. But Frances is concerned they’re casting too wide a net and that in order to capture the very rare person whose symptoms may develop into full blown depression, they will simultaneously ensnare – and medicate – many millions of people who are just going through a normal, albeit excruciatingly painful, life experience.