Ringing the Bell to Save the Bereavement Exclusion.
Of the multitude of miseries humans endure, is there something special about the death of the people we love? The move to eliminate the bereavement exclusion (BE) (See: "Let the Bereavement Exclusion in DSM-5 Die") to the diagnosis of MDD in DSM-5 asserts that a major depressive episode (MDE) after loss of a loved one lacks any meaningful difference from an MDE after any other form of loss. Proponents of eliminating the BE argue that undoing this distinction is important for diagnostic consistency and to provide rapid treatment to bereaved people who experience symptoms of an MDE.1,2 I disagree, on both scientific and humanistic grounds.
Those who argue for the termination of the BE take the position that until a meaningful difference is proved, in patients with at least 5 MDE symptoms for 2 weeks, a diagnosis of MDD should be made, regardless of any originating cause.2 (Those opposed argue that human grief, so various in its manifestations, so imperfectly understood, and so universal in its experience, should be distinguished as a unique phenomenon until convincing evidence emerges that grief can be reliably divided into normal and pathological. (Although some researchers2 suggest extending the minimum period of MDE symptoms required for an MDD diagnosis to 4 weeks from 2, this does not address the central concerns about eliminating the BE raised here.)
Most clinicians instinctively respect the BE. They expect people suffering the loss of a deeply loved person will feel a sustained period of sadness; will lose pleasure in daily life; are likely to have trouble sleeping and concentrating; and will not want to eat much. They intuitively understand that time, space, and support are required for healing and adjusting to life without the deceased. To be sure, some people clearly develop profound depressive episodes soon after a close personal loss, manifested by significant suicidal ideation, psychotic symptoms, or a near complete loss of functioning. The criteria for BE in DSM-IV allow for MDD to be diagnosed in such cases.
Because the elimination of the BE addresses the most sacred and historically and culturally preserved of human experiences, the scientific evidence must be rock solid to justify psychiatry’s intrusion. Our current knowledge base is simply not that strong, with 2 important scientific weaknesses.
First, the studies cited as supportive of eliminating the BE have several major limitations. As proponents of eliminating the BE have acknowledged, the necessary studies to truly compare bereavement-related MDD and nonbereavement-related MDD have not been done3; rather, most reports on this subject are secondary analyses of data gathered for other purposes.4-6 While such findings may be suggestive, they cannot be considered sufficiently conclusive to justify changing the DSM criteria. Using clinical samples to assess the equivalence of bereavement- and nonbereavement-associated MDD reflects tremendous sampling bias; as such, treatment-seeking patients cannot possibly represent the majority of patients suffering from MDE-level symptoms of bereavement in the community.
It is important to note that no prospective community studies have evaluated patients within 2 months of the loss of a loved one. Retrospective studies are highly vulnerable to recall and recency biases that raise substantial doubts about the accuracy of the data. Retrospective community surveys cited in support of eliminating the BE have been either too small or not representative of the broader community.3,7 Moreover, the largest community survey data set used to examine this question concluded that people with bereavement-related MDE-level symptoms that met the BE as defined in DSM-IV have a unique symptom profile that does not predict a negative long-term course.8
Second, we must acknowledge that MDD is a clinical syndrome that lacks any consistent biological identifier. Others have written about the dangers of reifying our current diagnoses as if they were definitive forms of nature.9,10 The syndrome of MDD, although a source of tremendous suffering, is not a disease per se. It is a highly heterogeneous construct in terms of its etiology, natural course, and treatment responsiveness. To eliminate the BE in pursuit of scientific “consistency” for a clinical syndrome so pleomorphic only serves to further muddle our efforts to determine its pathophysiologies and identify reliable treatments for it.
Beyond the scientific concerns is the impact of DSM on cultural understandings of health and mental illness.11 Those who have proposed eliminating the BE have argued that we cannot know the social consequences for changing DSM, and therefore such considerations should not enter into the debate. Such a view is misguided. The uptake and broad public discussion of PTSD since DSM-III is a prime example of the power of DSM to alter social framing effects. There are foreseeable consequences to eliminating the BE for how society comes to view interpersonal loss. Those who would toll the bell for the BE in DSM-5 must recognize they are undertaking a redefinition of what it means to grieve in Western nations. The meta-message that will gradually enter the public consciousness is that if you are too upset for 2 to 4 weeks after someone you love dies, then you are mentally ill. Over time, the expectation will become that you need to move on from loss more quickly than what is currently acceptable, otherwise you need treatment.
An additional concern is how poorly and inconsistently MDD is diagnosed in primary care.12 For many patients who see their primary care physician when bereaved, antidepressant medication is likely to be prescribed if the DSM deems bereavement-related MDE-level symptoms to equate to MDD. Importantly, no studies have demonstrated efficacy of antidepressant medication over placebo for MDE-level bereaved patients treated within 2 months of their loss. Nevertheless, if there is a diagnosis, there must be treatment, and if psychotherapy is not available, affordable, or desired, that treatment will be medication.
As a researcher, I understand the “unscientificness” of segregating out an etiology of a phenotype without strong evidence for its distinctiveness. However, as a physician concerned about the health of the public and the broader perception of our field, I am loathe to eliminate the BE. Psychiatry should be humble in its conceptualizations of illness, given how much interindividual variability we encounter within our current diagnostic schema. We really cannot get around the fact that meaning matters-that how people conceptualize the importance and consequences of personal events has an enormous effect on their mental health. Once we, as a field, step onto the sacred ground of death, we are asserting a position of privilege regarding what the passing of a person should mean to someone, which I very strongly feel we should avoid, unless the evidence to support it is irrefutable.
For psychiatry to justify further intrusions into diagnosing illness during bereavement, prospective studies will need to be performed that evaluate symptoms, natural course, and the effects of treatment in recently bereaved individuals who do and do not meet MDE criteria, individuals who have an MDE after other major life stressors, and individuals who have an MDE spontaneously in the absence of a stressful event.
I believe we should let the BE be-even if it is imperfect. It allows us to diagnose and treat MDD if the person is seriously impaired from the loss but does not overreach beyond our current state of knowledge.
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