Is a pill the right medicine for grief?

THE BRUTAL murder of 20 children and seven adults has burned the small Connecticut town of Newtown into the national consciousness. News crews, charitable organizations and friends of the families descended upon the town to provide coverage and support in the aftermath of the tragedy. These temporary visitors will pack up and move on, and the real grief for the victims' families will begin. Anyone who has experienced loss knows, after a month or two, that people stop calling to check in or offering to bring over dinner. It's not callousness-It's just that life goes on.

After Newtown, we are looking for ways to avoid history repeating itself - some by calling for a discussion about gun control, others by demanding greater focus on mental health. While this conversation is necessary, there is a mental-health issue not being discussed as much that more directly impacts the families in Newtown: grief and how it is processed.

When people suffer a loss - whether it is the senseless murder of a sibling, the early death of a parent to cancer or even the loss of a beloved pet - we typically go through a period of grief. Confronting and processing the loss is often a painful experience, as we realize that those we love will never walk through the front door again. We may experience sadness, anger, confusion, and a whole range of complicated feelings.

Although difficult, and sometimes cripplingly so, experiencing and processing these feelings, often with the assistance of mental-health professionals, can further the healing process and help those suffering from grief recover from their loss. For the past 32 years, grief after a loss has been best understood by the mental-health community to be a natural, if painful, response best addressed through therapy and not medication.

This spring, however, the authoritative guide on mental-health diagnoses and treatments - the Diagnostic and Statistical Manual (DSM) - is being significantly revised to identify grief as a medical condition that can be treated pharmacologically with antidepressants. Previously, in the DSM, a major depressive disorder was classified as experiencing five symptoms of major depression for two weeks or more. These symptoms include sadness, difficulty sleeping, decreased appetite, fatigue, diminished pleasure and difficulty concentrating. Because many individuals experiencing grief have these symptoms for more than two weeks, the DSM had a bereavement exclusion. This exclusion reasoned that for recently bereaved individuals, if the symptoms lasted for less than two months, absent additional features (such as contemplating suicide), this should be regarded as normal grief and not classified as major. The bereavement exclusion had the practical effect of treating normal grief through therapy and not medication.

Now, based on some methodologically questionable studies, some of which were funded by the pharmaceutical industry, the new DSM removes the bereavement exclusion. Therefore, once this version hits the bookshelves of medical practitioners, grief will be a medical condition presumptively to be treated with antidepressants.

Why does this matter? It matters because the DSM is, in effect, the bible of mental health, relied upon by medical professionals, including general practitioners who prescribe the majority of antidepressants, to diagnose individuals. Therefore, the removal of this bereavement exclusion means that many bereaved individuals whose grief would otherwise normally ease over time will be given prescriptions for pills after the death of a loved one. These pills are unlikely to meet the needs of a person experiencing normal grief. In fact, for such an individual, these pills could mask their pain and save the real "grief work" for down the road, potentially complicating the grief.

Another risk associated with this change is the effect it can have on insurance-company reimbursements. The DSM sets the standards by which insurance companies determine what they will and will not reimburse. There is the possibility that insurance companies might reduce the number of reimbursable talk-therapy sessions for a grieving person, based on the premise that this grief can be solved by taking a pill, which would push patients away from therapy that might be more appropriate for them.

There are times when an antidepressant is appropriate. Yet, the reasoning and studies behind this change to the bereavement exclusion will make treatment with antidepressants the norm, rather than the exception. Such overmedicalization will hinder the healing process, whether the grief is because of a public massacre or the more private loss of a loved one.

Post-Newtown, the collective call for a discussion on mental health is warranted. That discussion must include an honest dialogue on how to best help those who lost loved ones process their grief, including how to prescribe and use antidepressants appropriately. The Newtown tragedy can help us begin a fruitful discussion on how people grieve, learn about organizations in our communities that help grieving families, and begin the process of healing . . . without a pill.