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When does a broken heart become a mental disorder?

This statement was developed by a workgroup at the meeting of the International Work Group on Death, Dying and Bereavement in Victoria, British Columbia on April 28 – May 3, 2013. You have full permission to translate the document into other languages, and to distribute it via websites, blogs, the media, and other venues. It is our intention that the message be shared widely.

When does a broken heart become a mental disorder? Rarely, if ever.

But don’t tell that to the American Psychiatric Association, which has just released its fifth version of the
Diagnostic and Statistical Manual of Mental Disorders. The DSM is a catalogue of mental disorders,
hundreds of them, each trailing a listing of symptoms. The manual informs selection of a diagnosis,
which is required by U.S. insurance companies for reimbursement for mental health care.

There’s a major change in the newest version, DSM-5, with serious implications for the millions of
people who are coping with the death of a child, spouse, parent, friend, or other loved one.

But first, a quick glimpse at the history of this publication, often referred to as the bible of psychiatry.
The very first edition, published in 1952, didn’t even refer to grief, considering it an accepted and
normal reaction to the death of a loved one. The third edition added an exclusion statement under
Major Depressive Disorder, referred to as the “bereavement exclusion.” Under this exclusion, a
diagnosis of Major Depressive Disorder could not be made for a full year after a death. They recognized
that normal and common reactions to the death of a loved one could look like symptoms of depressive
disorder, for example, sadness, disturbed sleep, lack of concentration, changes in eating, and loss of
interest in things that were once pleasurable.

In 1994 the 4th version of the DSM reduced the bereavement exclusion to two months after a death, and
this new version removes the bereavement exclusion completely, meaning in effect that anyone can
receive a diagnosis of Major Depressive Disorder two weeks after the death of a child, parent, spouse,
friend, or anyone.

Why does this matter? For at least three reasons:

First, normal reactions to the death of a loved one will be easily misclassified as the mental disorder
depression. Grief is not the same experience as major depressive disorder. It is not an illness to be
treated or cured. It is a healthy response to a painful reality that one’s world is forever altered, and will
never be the same. Absorbing this loss, and adapting to all the changes it unleashes, has its own unique
course for every person, and will not be stilled or stopped by quick fixes or simple solutions. Death is a
life-altering event, but grief is not a pathological condition.

Second, antidepressants are commonly and frequently prescribed. There is a strong likelihood that
newly bereaved people will qualify for a diagnosis of Major Depressive Disorder just two weeks after a
death even though their reactions are normal. Antidepressants have not been shown to be helpful with
grief-related depressive symptoms, and there is accumulating evidence of long-term negative effects of
being on antidepressants. We need to ask why psychiatry is pathologizing grief and therefore making
inappropriate pharmacological treatment easier. And we should not overlook the self-interest of
pharmaceutical companies who see a new and substantial market for antidepressants, currently a multi-billion
dollar industry.

Third, about 80% of prescriptions for antidepressants are written by primary care physicians, not
psychiatrists. We have the expectation that physicians, as well as psychologists, social workers, and
clergy, to whom many of us turn for help after losses of all kinds, have professional training, solid
research backing, and supervised experience to guide them. Some do, but in fact, a considerable
majority of practitioners with these degrees have no professional training at all in responding to the
bereaved.

The caution here? Be wary of physicians or other medical professionals who rush to prescribe antidepressants
to address your grief.

Here’s a better prescription: Mourn the death of your loved one in your own way. There is no prescribed
formula. You may cry; you may not. Your reactions will be shaped by many things: the relationship you
had with the deceased, your personality style, and the support or lack of support you receive from
others. Push aside those who tell you to move on, that every cloud has a silver lining. What one person
finds comforting might not work for another. Find friends and family who understand, and with whom
you can share your experience. If they won’t listen or help, or if their help is not enough, search for
support groups through your local hospital, hospice or community organizations. Don’t be afraid to seek
professional help, but if you do, ask about the person’s training, qualifications, and experience with
grief, loss, and bereavement.

We grieve as deeply as we love. We can get off track with love, and we can respond to our grief in ways
that aren’t healthy, or don’t serve us well. But let’s not make love, or grief, a mental disorder.

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This document was written by a group of concerned professionals in response to the release of the
American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders ( DSM-5).

Thomas Attig, PhD, Professor Emeritus in Philosophy, Bowling Green State University
Inge B.Corless, RN, PhD, FAAN, Professor, MGH Institute of Health Professions, Boston, MA
Kathleen R. Gilbert, PhD, Executive Associate Dean, Indiana University School of Public Health, Bloomington, IN
Dale G.Larson, PhD, Professor, Department of Counseling Psychology, Santa Clara University, CA
Mal McKissock, OAM, Director of Clinical Services, Bereavement Care Centre, Sydney, Australia
David Roth, Executive Director, Puetz-Roth Funerals and Grief Companions, Bergisch Gladbach, Germany
Donna Schuurman, EdD, FT, Executive Director, The Dougy Center for Grieving Children & Families, Portland, OR
Phyllis R. Silverman, PhD, Scholar-in-Residence, Women’s Studies Research Center,
Brandeis University, Waltham, MA
J. William Worden, PhD, ABPP, Psychologist, Laguna Niguel, CA

We would like to acknowledge the International Work Group on Death, Dying and Bereavement (IWG)
for the opportunity to develop these ideas. This statement represents the opinions of the authors, not
the opinions of the Board or membership of the IWG.

Click here to download PDF of this statement.