Opponents in the now well-worn, “Bereavement Exclusion” debate can probably agree on one thing: of all the proposed changes in the DSM-5, the move to eliminate the bereavement exclusion has ignited the most intense emotional reaction among the general public.
Opponents in the now well-worn, “Bereavement Exclusion” (BE) debate can probably agree on one thing: of all the proposed changes in the DSM-5, the move to eliminate the bereavement exclusion has ignited the most intense emotional reaction among the general public.1 It’s no wonder: the deeply painful experience of losing a loved one is almost universally understood. In an important sense, nearly everyone is an “expert” in the matter of bereavement.
To be sure, there have been sincere and thoughtful critiques on both sides of the debate, as discussed recently by my colleague, James Knoll, IV, MD.2 There have also been some vitriolic, over-the-top attacks directed at the DSM-5 Mood Disorders Work Group; the American Psychiatric Association (APA); and psychiatrists who favor the elimination of the Bereavement Exclusion. By way of disclosure: I do favor elimination of the BE, and I am a member of the American Psychiatric Association. However, I am not a part of any DSM-5 work group, nor have I conveyed any formal recommendations to the APA or the DSM-5 task force members-until now.
I believe it is time for the issue of the bereavement exclusion to be reviewed by an independent, “blue ribbon,” scientific panel-ideally, under the auspices of the NIMH, the National Academy of Sciences, or the National Science Foundation. Why now, and why this particular issue? Actually, I have called for independent review of the entire DSM-5 project on several occasions; but given the increasing public uproar over the BE, I believe that an independent review is necessary to restore public confidence in whatever decision the Work Group ultimately makes. Recently, I have also been canvassing the directors of mood disorder programs in the United States, and-while only a handful have responded so far-I have been surprised by the spectrum of views regarding the BE. While none of the mood disorder experts endorsed the view that the BE is based on sound science-a sobering but not at all surprising finding-several questioned the wisdom of eliminating the BE from DSM-5. These doubts were usually framed in terms of the public’s perception of psychiatry, rather than of disagreement with the evidence supporting elimination of the BE.
Alas, as things stand, members of the Mood Disorders Work Group are caught between the proverbial rock and a hard place. If they simply reverse themselves and retain the BE in the DSM-5, critics of psychiatry will loudly denounce the “politics” of psychiatric diagnosis and accuse the Work Group of “caving in” to public pressure. If they simply hold fast to their current position of eliminating the BE, the Work Group will be excoriated for “medicalizing normal grief” and “handing a gift to the pharmaceutical companies!” My hope is that an independent panel’s recommendation will help guide the Work Group out of this knotty double-bind, toward a feasible solution. I also think it essential that the DSM-5 Work Group tries to harmonize their decision with the forthcoming ICD-11 (International Classification of Disease, 11th ed). It is important to note that the ICD classification of mood disorders has never endorsed a formal “bereavement exclusion” in the diagnosis of major depression.
The question of eliminating the BE is complicated by 2 subsidiary problems inherent in the DSM-IV. The first is the arbitrary and unhelpful “2 week/2 month” conundrum. The “2 weeks” refers to the minimum duration required for establishing a major depressive episode; and derivatively, for diagnosing major depressive disorder (MDD). My colleagues and I believe that, for most patients, 2 weeks is too short a time to permit a confident diagnosis of MDD-whether after bereavement, or any other major loss (divorce, job loss, etc.).3 In a few cases-for example, when a patient presents with virtually the same depressive symptoms as in one or more previous episodes of MDD-the 2-week minimum may make sense. It also makes sense when melancholic features are present. But for most non-melancholic patients with no previous bouts of MDD, presenting to a clinician only 2 weeks after a major loss, I believe waiting an additional 1 to 2 weeks is prudent, before reaching a formal diagnosis. The additional time permits a more accurate assessment of the patient’s “trajectory,” with respect to functional capacity, symptom intensity, and suicidal risk. The added interval also permits a better determination of what, if any, treatment is indicated.
The other part of the conundrum is the procrustean DSM-IV guideline regarding “normal” bereavement. This V-code diagnosis extends for only 2 months after the loss, and applies only in the absence of certain “severity” indicators, such as marked functional impairment, suicidal intentions, and marked psychomotor retardation. As many experts on grieving have argued-and as millions of bereaved individuals know-this 2-month limit is both arbitrary and misleading. “Normal” grief is highly individualized, and may extend for many months, or even years, after the death of a loved one. Ordinary grief also has a characteristic “phenomenology” that distinguishes it from MDD, as well as from “complicated grief” (CG) (which may find its way into the DSM-5 in the guise of “Adjustment Disorder Related to Bereavement”).4
Any decision regarding the bereavement exclusion should also take into account the “2 week/2 month” conundrum. My personal preference would be for elimination of the BE, accompanied by (1) expansion of the 2-week minimum MDD interval to 3 to 4 weeks; and (2) elimination of the 2-month limit on normal bereavement. If the 2-week criterion is not formally changed, the text of the DSM-5 should at least reflect the need for flexibility and clinical judgment in applying the MDD duration criterion.
True: making too many changes in one’s diagnostic system is always fraught with risk; however, the guiding principle should be what is best for our patients, and what the best evidence tells us-not an unreasoned allegiance to arbitrary and outdated criteria. Indeed, this is precisely why the BE itself should be shown the diagnostic door. Perhaps most important, clinicians need a clearer description of ordinary grief following bereavement. This could be provided in the DSM-5 text, as well as in a “V” code for “Ordinary Grief of Bereavement”-which, of course, would not be deemed a “mental disorder.” Ultimately, I hope that we are able to develop screening tools to help clinicians distinguish bereavement-related grief from MDD and complicated grief.5
Regardless of the final decision re: the BE, the APA leadership will have its work cut out for it, on 2 levels: first, in educating psychiatric and primary care physicians in the nuances of the new guidelines; and second, in explaining to the general public why these significant changes were made. To be sure, physicians-particularly those in primary care-will need more robust education as to when antidepressants are and are not the most appropriate treatment for MDD. But this is a didactic challenge, not a diagnostic issue; and the DSM criteria should not be molded into vehicles of social engineering.
Since the DSM-5 is to be finalized this fall, an independent review of the bereavement exclusion needs to be initiated immediately. I believe it could be completed within 4 to 6 months, and-if the reviewers maintain “science in the public interest” as their preeminent concern-I believe the review will support elimination of the bereavement exclusion. In any event, I envision this as an advisory opinion to aid the DSM-5 Work Group-not as a binding determination. There is precedent for this model; for example, the FDA does not always take the recommendations of its advisory committees. I believe the “final call” on the BE should still be up to the DSM-5 Task Force and leadership. And that decision should be based not on popularity polls or public outcries, but on the best scientific evidence and the best interests of our patients.
Acknowledgment: I want to thank Dr Sidney Zisook for his comments on an earlier draft of this piece.
References1. Francis A. More than 65,000 grievers must be heard-and should be heeded. Psychiatr Times. March 6, 2012. http://www.psychiatrictimes.com/blog/frances/content/article/10168/2042902.
2. Knoll JL. Sinking into grief. Psychiatr Times. April 2, 2012. http://www.psychiatrictimes.com/display/article/10168/2054050.
3. Lamb K, Pies R, Zisook S. The Bereavement Exclusion for the diagnosis of major depression: to be or not to be? Psychiatry (Edgemont). 2010;7:19-25.
4. Zisook S, Simon N, Reynolds C, et al. Bereavement, complicated grief, and DSM, part 2: complicated grief. J Clin Psychiatry. 2010;71:1097-1098.
5. Pies R. After bereavement, is it “normal grief” or major depression? Psychiatr Times. Feb. 21, 2012. http://www.psychiatrictimes.com/blog/pies/content/article/10168/2035804