The Diagnostic and Statistical Manual of Mental Disorders (DSM) has historically been criticized as an unreliable diagnostic tool. At this point, we have no scientific way of testing for mental disorders. Diagnosis is strictly based on a cluster of observed and self-reported symptoms.
Critics argue that several of the disorders listed in the DSM are normal human experiences characterized by extreme stress or sadness. People experiencing such issues can benefit from therapy, but in order to receive financial reimbursement from insurance companies, the individual must be diagnosed with a clinical mental disorder.
Being diagnosed with a mental disorder in cases of transient episodes places the patient at risk of becoming a potential candidate for psychiatric medication. This is problematic insofar that these medications often have negative side effects that can be counterproductive for their treatment.
There is a significant difference between struggling with life stressors in which counseling can help versus having a persistent mental disorder that needs to be medicated and treated with therapy.
One of the most controversial changes to the fifth edition of DSM (DSM-5) is that the bereavement exclusion has been deleted from the diagnostic criteria for Major Depressive Disorder (MDD), which now allows clinicians to diagnose grieving individuals with depression.
The American Psychiatric Association (APA) decided to include grief under the umbrella of MDD in DSM-5 because DSM-IV did not exclude other losses, such as divorce. The rationale was 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?
Does DSM-5 Pathologize Normal Grief?
The problem with DSM-5’s logic is that there is a significant difference between clinical depression and feeling depressed in response to grief, divorce, and/or some other traumatic event. MDD 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, sleep 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 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.
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.
Of course, 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-5, 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.
An Alternative Approach to Recognizing Depressive Symptoms
One of the biggest problems with treating normal grieving like depression is that psychiatric medication combined with psychotherapy has become the first line of treatment for this condition.
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. 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 may 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 people are constantly coming into contact with stressors (poison ivy), which have the potential to trigger a depressive episode (skin rash). A person can begin dealing with these feelings by doing something self-soothing and relaxing. Proper diet and moderate exercise can help stabilize the 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 the skin.
If a person’s depression continues for several weeks and negatively affects his/her ability to function, he/she may want to meet with a therapist. Hopefully, this individual will be able to work through his/her problems and move on with life.
If a combination of proper diet, exercise, and psychotherapy doesn’t help, then this individual 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.
The Problem of Reimbursement for Diagnosis
Medicine doesn’t solve problems. Many people with depressive symptoms 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 normal human experiences, we need to be able to bill insurance companies for treating psychosocial stressors (DSM-IV Axis IV psychosocial and environmental stressors).
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 for many reasons, not the least of which is because they, like people with clinical depression, are at increased risk of suicide.
How DSM-5 Fuels Overdiagnosis
Another danger associated with diagnosing people with mental illnesses that they don’t really have is that it distorts prevalence rates, which has serious implications for understanding mental illness in society. Our society relies far too heavily on the DSM to legitimize emotional experiences. Some clinicians have been brainwashed into believing that if a person’s feelings and behaviors aren’t listed in the DSM, then their problem doesn’t exist. And if a person’s feelings and behaviors are listed in the DSM, then there is something fundamentally wrong with them that needs to be fixed.
The truth is that all 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 midst of a crisis, medication may be helpful, eg, a benzodiazepine to calm someone down. But in the long-term, there is no benefit of taking antidepressants for someone experiencing a transient depressive episode.
We are living in a consumer age where antidepressants are constantly being advertised in the media. Average people have been taught that numbing their emotions with psychoactive drugs is the efficient way to cope with distress. Just like fast foods and speedy highways, everyone is 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.
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 pathologizing normal human experiences like grief.
Photo courtesy of Quinn Dombrowski on flickr