Jerome C. Wakefield, PhD

Psychiatrists Should Not Fall Back on DSM

The Lure of the Context-Dependent Psychiatric Diagnosis

Major Depression After Recent Loss Is Major Depression-Until Proved Otherwise

 December 2008, page 12), Dr Ronald Pies critiques our earlier article (“

The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder

 (Oxford University Press). We had argued that 

’s reliance on decontextualized symptomatic criteria to define major depressive disorder (MDD) confuses disorder with intense normal sadness in response to loss, which frequently includes 

/MDD–like symptoms. To improve validity, we proposed extending the current MDD bereavement exclusion-which excludes “uncomplicated” (relatively brief, lacking certain severe symptoms) depressive bereavement from diagnosis-to also exclude uncomplicated reactions to other major stressors, such as romantic breakups, job loss, and serious medical diagnoses. The evidence (presented in our book) suggests that such uncomplicated responses are frequent but mostly transient and are likely normal–range responses.

Dr Pies, to the contrary, proposes eliminating the bereavement exclusion and maintains that even uncomplicated depressive reactions to loss are disorders. However, many of his arguments fail to support his position:

 Pies questions whether there are controlled, prospective data showing self–limited course and lack of treatment response in uncomplicated bereavement–related depression. A vast amount of evidence cited in our book, including many prospective studies, indicate high MDD–level symptom rates immediately following major loss that decline steeply over time. This is why the bereavement exclusion was introduced and why its extension is warranted.

 Pies’ focus on treatment studies confuses drug response with disorder status. Ritalin helps with attention–deficit/hyperactivity disorder and with studying for examinations, and Valium helps with generalized anxiety disorder and normal performance anxiety. Even if antidepressants help with normal grief (the jury is still out), that wouldn’t imply that the recipient has a disorder. We are not opposed to medicating patients with normal distress; rather, we object to mislabeling conditions as disorders, thus biasing prognosis, informed consent, and treatment planning.

 The 2 studies Pies cites in his commentary as support reveal the poverty of evidence for his position. In the first study, Karam and colleagues1 showed uncomplicated MDD to have recurrence rates similar to complicated MDD but, as they acknowledge, their uncomplicated samples were “too small to allow for generalization.” The second study is irrelevant because Brent’s

 adolescent sample had depressions of 8 months’ average duration, outside the “uncomplicated” domain. In addition, Pies did not consider our own empirical study that showed that the incidence of uncomplicated MDD following bereavement and other stressors is markedly lower on pathology indicators than complicated cases.

 Pies also fallaciously concludes that, because errors of causal attribution can occur, “trigger” is a nebulous notion. In fact, the role of stress in triggering depressive episodes-with additional causal factors, of course-is one of the best–confirmed hypotheses in psychiatry. Despite the inevitable possibility of error, physicians throughout history have considered context crucial in MDD diagnosis.

 Pies quotes a historian’s opinion that physicians helped people without attending to normality versus disorder. While it is true that physicians have always helped suffering people-with or without a disorder-they have also explicitly addressed the diagnostic issue of whether the patient’s distressed condition is normal or disordered. The historian notes “no clear, bright line between disease and health.” This is true, but neither is there a bright line between, say, child and adult. The distinction between normal and disordered sadness is similarly real despite considerable boundary fuzziness, with clear cases on both sides-some of which are misclassified by 

Pies objects to assessing whether MDD symptoms are “proportional” to context without a research–validated scale. However, many criteria sets require clinicians to judge without formal scales whether symptoms are “excessive” or “unreasonable”-proxies for proportionality-to distinguish mental disorders from normal responses. MDD is the exception.

) that myocardial infarctions (MIs) are triggered by stress but are disorders nonetheless. We know MIs are biological dysfunctions. Genuine disorders, whether MIs or “complicated” depressive reactions, can of course be caused by environmental stress. But sadness, unlike MI, is biologically designed to occur in reaction to specific environmental events, so judging whether MDD symptoms are pathological requires reference to context.

Pies, lacking scientific evidence, disparages commonsense observation of human nature at psychiatry’s peril. If 

 eliminates the bereavement exclusion, thereby making intense depressive grief after loss a disorder, not only the validity but the credibility of psychiatric diagnoses will be undermined, playing into the hands of the antipsychiatry movement.

Dr Wakefield is university professor, professor of social work, and professor of the conceptual foundations of psychiatry, as well as affiliate faculty in bioethics and in the Center for Ancient Studies at New York University. He is the author of more than 150 publications on the conceptual foundations of the mental health professions. He is author with Allan Horwitz of 

The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder 

(Oxford, 2007), named best psychology book of 2007 by the American Association of Professional and Scholarly Publishers.

Dr Horwitz is professor of sociology and dean of social and behavioral sciences at Rutgers University in New Jersey. In addition to 

 he is the author of 4 other books and over 75 articles and book chapters on social aspects of mental illness.

Neither author has any disclosures to report of conflicts of interest or financial support.

 Karam EG, Tabet CC, Alam D, et al. Bereavement related and non–bereavement related depressions: a comparative field study. 

 Brent DA, Perper JA, Moritz G, et al. Major depression or uncomplicated bereavement? A follow–up of youth exposed to suicide. 

 Wakefield JC, Schmitz MF, First MB, Horwitz AV. Extending the bereavement exclusion for major depression to other losses: evidence from the National Comorbidity Survey. 

 Zisook S. Commentary on chapter 1, “diagnosis of depressive disorders.” In: Herrman H, Maj M, Sartorius N, eds. 

 3rd ed. Vol 9. Hoboken, NJ: John Wiley & Sons. In press.

[Editor–in–Chief’s note: Since my editorial drew heavily on the work of Sidney Zisook, MD, and colleagues, I have invited Dr Zisook to serve as coauthor of this response.]

We appreciate the detailed rejoinder from Professors Wakefield and Horwitz (henceforth, W–H). Obviously, no competent psychiatrist believes that mere “sadness” is a pathological condition that requires professional treatment or considers uncomplicated grief an illness. We no more want to “medicalize” a normal condition (grief) than W–H want to “normalize” a pathological one (eg, MDD). But if-absent appropriate data-W–H are claiming that “non–disordered sadness” is the proper designation for a syndrome that meets full severity and duration criteria for MDD but which occurs within 2 months of a major loss, then they are simply engaging in an elaborate renaming exercise. We can rename pancreatic cancer “pancreatic hyperplasia,” but it remains a fatal disease. Renaming as “appropriate sadness” 

 major depression that occurs within 2 months of bereavement does not show that this condition is less debilitating than major depression without recent loss. Indeed, most data suggest that MDD with loss is every bit as debilitating, “biological,” and recurrent as major depressive syndromes that occur in any other context, with or without clear–cut environmental precipitants.

We certainly agree that attention to context may help formulate personalized treatment interventions and influence outcome. But context should not define diagnosis. In many ways, W–H’s thesis harks back to the pre–

 categories of type A depression (severe illness, akin to W–H’s complicated MDD) and type B depression (mild illness, more like W–H’s “uncomplicated” group).

 Other terms for this dichotomy included autonomous–reactive, endogenous–exogenous, psychotic–neurotic, and endogenomorphic–nonendogenomorphic.

 Yet features intended to differentiate type A and B depressions, including the presence of precipitating events, failed to validate these subtypes.

 Indeed, “it is difficult in clinical practice to discriminate between different categories of depression on the basis of presence or absence of a psychic trauma or a stressful life event … the inherent problem may be that it is difficult to decide whether a present life event … constitutes a psychic trauma for the individual patient or not.”

 which supposedly supported the W–H thesis, retrospectively evaluated individuals who met MDD symptom criteria and whose MDD episodes were triggered by either bereavement or other loss. Subjects were subdivided into “uncomplicated” and “complicated” cases. Essentially, those with “uncomplicated” cases lacked suicidal ideation, marked functional impairment or psychomotor retardation, feelings of worthlessness, or prolonged duration of symptoms. The study found that:

• MDD after bereavement was far more similar to than different from depressive syndromes that occurred after other stressful life events.

• Those with “complicated” cases showed more severe pathology than those with “uncomplicated” cases (a finding we consider essentially tautological).

The researchers reached 2 main conclusions:

• Bereavement–related depression does not deserve special diagnostic status compared with other life–event triggered depression. We agree with this conclusion.

• All “uncomplicated,” “triggered depressions” should be exempt from the diagnosis of MDD. We disagree with this conclusion. This study did not compare depression “with and without cause” (indeed, fewer than 5% of all cases lacked an identifiable environmental trigger!); nor was it prospective.

Moreover, as the authors noted, “the accuracy of the … respondents’ self–reports of triggering events is unknown; respondents may misremember whether there was an event, or whether the timing of an event was before an episode. Further, they may misattribute the cause of an episode to an event when they were coincidental.” We fully agree! Furthermore, as Dr Glen Gabbard observes:

Often the stressor identified by the patient (or therapist) is retrospectively assumed to be the cause [of the depression] because it fits a particular intrapsychic narrative-often one involving victimization. It’s rarely that simple. Often there are multiple stressors; issues involving adult developmental phases; dashed fantasies and hopes; and failures to live up to the expectations of internalized parents (personal communication, December 31, 2008).

Another large community epidemiological study also found many more similarities than differences between bereavement–related depressive syndromes and depressions related to other, nonbereavement life events.

 This study failed to support the special status accorded “bereavement” in 

. The authors concluded, “bereavement–related depression often is recurrent, genetically influenced, impairing, and treatment responsive. These are all characteristics that are likely to be more associated with ‘MDD’ than with ‘normal sadness.’”

We acknowledge that the data are not conclusive and allow room for debate. Opinions regarding the bereavement exclusion or the exclusion of “triggered” depression from the category of MDD are based largely on “clinical wisdom” and interpretations of studies that were not designed to answer these questions. A definitive study would require prospective comparison of persons whose depressions occur in the context of several common life stressors with persons whose depressions appear unrelated to environmental triggers on symptom profile and duration, hospitalization rates, suicide attempts, social and vocational impairment, course, and so on. We do not believe there are any current studies that conform to these parameters. Nevertheless, based on our clinical experience and the preponderance of available evidence, we conclude that continuing the bereavement exclusion in DSM–V would be a serious error. It would encourage bereaved individuals, their families, and health care providers to ignore signs and symptoms of a potentially debilitating, life–threatening-yet treatable-disorder. Extending this exclusion to still other loss events could create a public health disaster. Our patients deserve better.

Dr Pies is professor of psychiatry and lecturer on bioethics and humanities at State University of New York (SUNY) Upstate Medical University in Syracuse and clinical professor of psychiatry at Tufts University in Boston.

Dr Zisook is professor and director of residency training, department of psychiatry, University of California San Diego and staff physician, VA San Diego Health Science Center.

 Zisook S, Shear K, Kendler KS. Validity of the bereavement exclusion criterion for the diagnosis of major depressive episode. 

 Kendler KS, Myers J, Zisook S. Does bereavement–related major depression differ from major depression associated with other stressful life events? 

 Kendell RE. The classification of depressions: a review of contemporary confusion. 

 Akiskal HS, Bitar AH, Puzantian VR, et al. The nosological status of neurotic depression: a prospective three– to four–year follow–up examination in light of the primary–secondary and unipolar–bipolar dichotomies. 

 Klerman GL, Endicott J, Spitzer R, Hirschfeld RM. Neurotic depressions: a systematic analysis of multiple criteria and meanings. 

 Leff MJ, Roatch JF, Bunney WE Jr. Environmental factors preceding the onset of severe depressions. 

 Paykel ES, Myers JK, Dienelt MN, et al. Life events and depression. A controlled study. 

 Kessing LV. Endogenous, reactive and neurotic depression-diagnostic stability and long–term outcome. 

 Kessing LV. Epidemiology of subtypes of depression. 

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To improve validity, we proposed extending the current MDD bereavement exclusion-which excludes “uncomplicated” (relatively brief, lacking certain severe symptoms) depressive bereavement from diagnosis-to also exclude uncomplicated reactions to other major stressors, such as romantic breakups, job loss, and serious medical diagnoses. 

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Major depressive disorder (MDD) has become psychiatry’s signature diagnosis. Depression is diagnosed in about 40% of patients who see a psychiatrist. This percentage is double that of just 20 years ago, and it is far higher than that of any other diagnosis. The World Health Organization (WHO) estimates that worldwide depression is the leading cause of disability for people in midlife and for women of all ages.

Consumption of antidepressants has soared since 1990. Roughly 10% of women and 4% of men in the United States take antidepressant medication at any time. By 2000, antidepressants were the best-selling prescription drugs of any type. Yet epidemiological studies suggest that there are still vast numbers of untreated depressed individuals. Consequently, primary care practitioners have been recruited as the first line of defense, and many now routinely screen patients for depression. To catch the problem early, a presidential commission has recommended that every adolescent in the country should be screened for depression by the time he or she reaches age 18. Screening is proceeding in some schools.

What accounts for this seeming epidemic of depression? Although depression has been part of the psychiatric canon since the earliest writing of the ancient Greeks, depression was a relatively insignificant diagnosis just 50 years ago. In our recent book, 

The Loss of Sadness: How Psychiatry Transformed Normal Misery Into Depressive Disorder

 (Oxford University Press), we argue that the recent pandemic of seeming depressive disorder is the result of changes in the psychiatric diagnostic system presented in 

 (and subsequent versions) has been one of psychiatry’s greatest accomplishments. It was the first to use observable symptoms, rather than unobservable (and undemonstrated) etiological processes, to define the various types of mental disorders. Its clear definitions of discrete categories of disorder enhanced diagnostic reliability, thus putting to rest antipsychiatric arguments about the spuriousness of psychiatric diagnosis. These definitions allowed psychiatrists to communicate in a common theory-neutral language, irrespective of theoretical perspectives, that improved the cumulativeness of research.

Yet, these undoubted achievements also entailed some important disadvantages. These drawbacks have become especially apparent in the definition of MDD, and have had substantial social consequences.

A diagnosis of MDD is warranted, according to 

, when a patient has at least 5 of 9 specified symptoms for at least 2 weeks, and the 5 symptoms include either depressed mood or an inability to derive pleasure from life. The sole exception is that bereaved patients are not considered to have a disorder if they otherwise meet the criteria, as long as their symptoms are not unusually severe and last no longer than 2 months. The reason for the bereavement exclusion seems obvious: people who respond to the loss of an intimate with intense sadness, sleep and appetite difficulties, a loss of concentration on usual roles, and the like, do not have a mental disorder. Rather, they are responding normally to a situation of intense loss. The distinction between sadness that is a normal result of painful losses and depressive disorder is a fundamental one that has been explicitly recognized throughout the 2500-year history of psychiatric medicine.

Yet, the bereavement exclusion raises the question of whether people with enough symptoms to meet the MDD criteria-after, for example, the unexpected loss of a valued job, the collapse of a marriage, the failure to achieve a highly valued goal, or the diagnosis of a life-threatening illness in oneself or a loved one-are similarly reacting normally to situations of intense loss. For thousands of years, until 

, physicians understood that these kinds of situational contexts were an important consideration in determining whether someone was experiencing normal-although intensely distressing-sadness or a depressive disorder in which something has gone wrong with mood processes and the sadness symptoms are no longer linked to the situation or likely to remit over time. Unlike many other diagnoses in 

, which contain qualifiers that require symptoms to be “excessive” or “unreasonable,” no such qualifiers exist for MDD. Aside from the bereavement exclusion, the diagnostic criteria do not take into account the context in which symptoms arise.

Ample scientific evidence-ranging from infant and primate studies to cross-cultural studies of emotion-suggests that intense sadness in response to a variety of situations is a normal, biologically designed human response. Recent epidemiological analysis suggests that the consequences of stressors can be either normal or abnormal, similar to those for bereavement.

 In its quest for reliability via symptom-based definitions that minimized concern with the context in which the symptoms appeared, 

 unintentionally abandoned the well-recognized, scientifically supported, indeed commonsensical distinction between normal sadness and depressive disorder.

The blurring of the distinction between normal intense sadness and depressive disorder has arguably had some salutary effects. For example, it has reduced the stigma of depression and created a cultural climate that is more accepting of seeking treatment for mental illness. Many people with normal sadness might benefit from medication that ameliorates their symptoms. However, the usefulness of medication for normal sadness, and especially the trade-off between symptom reduction and adverse effects, has not been carefully studied-partly because the necessary distinctions do not exist within the current diagnostic system.

The decontextualized definition of MDD, however, has had substantial costs. Since 1980, an enormous “medicalization” of unhappiness has occurred. Life’s ills-whether a failure to attain an expected promotion, ongoing conflict with a spouse, or overwhelming distress from coping with competing family and work demands-are too often treated as mental disorders based on the report of a few symptoms of sadness. The medicalization of social life triggered an immense rise in the consumption of antidepressants. The efficacy of these medications for the treatment of normal sadness is often overstated, and their potential to cause harmful effects has sometimes been underestimated.

The consequences of over-medication is particularly worrisome for children and adolescents who are being socialized into a belief system that equates personal suffering with mental disorder to be overcome by taking a pill. The blurring of normal sadness and depressive disorder might also be proceeding at the expense of the smaller group of people who have a true psychiatric disorder and who are in desperate need of adequate psychiatric treatment.

Psychiatrists need not be moralists, judging whether patients should or should not take medication for life’s normal disappointments and suffering. It is, however, each psychiatrist’s responsibility to diagnose as fully and as accurately as possible, and not to bias the patient’s decision regarding treatment by a diagnosis that mistakenly labels as a disorder what is likely a normal response that will abate on its own as the patient copes with a difficult life change. Watchful waiting as well as a range of empirically tested psychotherapeutic interventions that are demonstrated to be as effective as medication for treating nonsevere conditions might be substituted for prescriptions in such cases.

It might seem that the results of epidemiological studies show that there are vast numbers of patients with untreated pathology in the community who may benefit from psychiatric care. In fact, such estimates place the credibility of psychiatry at risk and make the field a target of media ridicule. Can anyone truly believe, as the WHO evidently does, that the one-tenth of the population it estimates to have MDD in a given year has a condition of equal severity on average to paraplegia or blindness? Artificially high prevalence rates and the consequent policy emphasis on unmet need for mental health treatment and prevention are well-intentioned; however, this can have the counterproductive effect of transferring scarce treatment resources from persons with MDD to those who do not have the disorder.

The American Psychiatric Association is currently developing 

. It will have the opportunity to supplement the symptom-based definition of MDD with a definition that emphasizes the importance of context in determining whether a given collection of symptoms indicates a mental disorder. One way to do this would be to follow the model of the anxiety disorders that often requires that symptoms be “excessive” or “unreasonable” relative to the context in which they arise. Alternatively, a new definition might build on the bereavement exclusion and also exclude conditions that arise from other major psychosocial stressors that are not unusually severe or prolonged.

It is possible that incorporating context into the diagnosis of MDD could make diagnoses more difficult in some cases and decrease reliability. Yet, the improved validity that should follow from more contextual diagnostic criteria would enhance the authority of the psychiatric profession. Most important, it would benefit people with either normal sadness or genuine mental disorders who deserve accurate diagnoses and the safest and most specific and effective treatments.

1. Wakefield JC, Schmitz MF, First MB, Horwitz AV. Should the bereavement exclusion for major depression be extended to other losses? Evidence from the National Comorbidity Survey. Arch Gen Psychiatry. 2007;64:433-440.

Major depressive disorder has become psychiatry’s signature diagnosis. Depression is diagnosed in about 40% of patients who see a psychiatrist. This percentage is double that of just 20 years ago.

Jerome C. Wakefield, PhD

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