H. R. SEARIGHT
ment.
While noting the commonality of the grief response across
species, Frances (2013) also raises moral and philosophical
objections to dia gnosing gri eving individuals with MDE. Frances
argues that there is something inherently offensive in reducing
grief to a disease: “Medicalizing grief reduces the dignity of the
pain, short-circuits the expected existential processing of the
loss, reduces reliance on the many well-established cultural ri-
tuals for consoling grief, and would subject grievers to unne-
cessary and potentially harmful medication” (Frances, 2013: p.
187). Medicalizing grief both impugns the integrity and “dig-
nity” of the survivors’ emotional experience, but also is disres-
pectful to the life that was lost (Frances, 2013). Grief and be-
reavement rituals are long-standing responses that have impor-
tant meaning in their specific culture. In some cultures such as
Japan, intense contemplation and melancholia have been seen
as signs of morally superior character (Kitanaka, 2012). MDE,
as a disorder is only beginning to be recognized in Japan (Kita-
naka, 2012).
Treating Grief: Harm or Enhancemen t
The implicit corollary of converting grief to MDD is that
within American medicine, diagnoses are inextricably tied to
available treatment. However, if bereavement can be treated
with pharmacotherapy, should it be?
Before further discussion of the moral side of this issue, it is
worthwhile to consider the impact of implicitly diagnosing and
overtly treating everyone exposed to a stressful live event.
Critical Incident Stress Debriefing (CISD), typically adminis-
tered as a group intervention, to persons exposed to life-threa-
tening traumatic events such as first responders, continues to be
commonly used, and often mandated. However, data from mul-
tiple studies suggest that the iatrogenic affects often outweigh
any benefit from CISD (Lohr, Hooke, Gist, & Tolin, 2004).
While there are likely multiple explanations for this finding, it
is likely that many first responders have a working coping style,
often including some element of avoidance, that is successful.
By forcing these individuals to repeatedly relive the trauma and
face the accompanying emotional turmoil, successful adapta-
tion may be prevented. Research on CISD suggests that pro-
viding psychological treatment to all who experience a trau-
matic event may actually harm those receiving it. Wakefield
(2011) notes that similar to PTSD, the meaning of bereave-
ment’s depressive symptoms depend on the context in which
they occur. Re-defining bereaved individuals as ill subject them
to unwanted treatment that may challenge pre-existing coping
skills.
However, if a medication can reduce symptoms and improve
functioning, should everyone losing a loved one be required to
simply “muddle through” (Horwitz & Wakefield, 2007: p. 23)
life’s inherent complications when there is a relatively conve-
nient pharmacological alternative? Aside from the possible side
effects of antidepressants and the finding that 30% - 40% of
patients prescribed these medications fail to improve, is there
potential harm from labeling all recently bereaved individuals
as psychiatric patients? As a clinician, the author remembers
the days before SSRIs when tricyclic antidepressants (TCAs)
were commonly prescribed. While SSRI’s are not free of side
effects, they are not usually as disruptive as the pronounced
sedation, and anticholinergic effects during the first 7 - 10 day s
of taking a TCA. The question remains—if there are few ad-
verse medication effects and the patient appreciates the possi-
bility of being a non-responder, is there any reason not to be
treated for bereavement?
If grief is seen as having little value and as an unfortunate
life event that temporarily impairs functioning, the availability
of pharmacotherapy to aid in coping should be welcome. Simi-
lar to cognitive enhancement with drugs such as Modafanil
which extend concentration, antidepressant medication can re-
duce some of the distress accompanying bereavement. Critics
of psychiatric enhancement are often described as espousing
“pharmacological Calvinism” (Klerman, 1972), a view that dif-
ficulties in cognitive-emotional functioning are meaningful,
character-building burdens to be shouldered rather than atte-
nuated with psychotropic medication. Calvinism in particular,
is relevant when it comes to bereavement. Medication may
“cheapen” the experience of grief by making it less intense and
disruptive to one’s life. In some cultures, an individual demon-
strating little sadness after the loss of a parent or spouse would
be considered deviant because of the absence of extended
mourning. Contemporary mental health Calvinists, argue that it
is immoral to feel “good” after the loss of a loved one. Indeed,
even in industrialized countries such as the US, there is concern
that getting back to “normal “ too soon is a form of denial and
will be associated with a high level of unresolved grief or de-
layed emotional upheaval.
Conclusion
This essay has reviewed the clinical, empirical, and philoso-
phical issues raised by both proponents and opponents of the
DSM-5 bereavement exclusion. Whether widespread clinical
application of DSM-5’s bereavement exclusion will increase
the incidence of MDE diagnoses remains to be seen. In addition,
how readily patients will seek and accept pharmacotherapy to
address the grief of interpersonal loss is also an open question.
The “ground work” for pharmacotherapy of bereavement has
been laid with the use of SSRIs to “buff up” one’s personality
(Kramer, 1993), and drugs such as modafanil to improve cogni-
tive functioning a nd eliminate fatigue associ ated with shift work.
However, bereavement, with its often specific cultural and reli-
gious context, does not appear comparable to these other uses
of enhancement therapy. The ethical issues surrou nding “ar tifici al”
coping with loss through the medicalization of bereavement are
likely to continue to be debated.
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