DSM5 Criteria Won’t “Medicalize” Grief, if Clinicians Understand Grief

“The exclusion of symptoms judged better accounted for by Bereavement is removed because evidence does not support separation [or] loss of loved one from other stressors.”¹

With this simple rationale, the framers of DSM5 would, according to Dr Allen Frances,  “…reverse 30 years of diagnostic practice and allow the diagnosis of Major Depression to be made for individuals whose grief reaction symptomatically resembles a Major Depressive episode.”²

We respect Dr Frances’s numerous attempts to improve the DSM5 process and acknowledge that he has raised important questions about several proposed DSM5 diagnoses.² However, we support the proposal to eliminate the bereavement exclusion from the criteria for Major Depressive Episode (MDE) and disagree that this amounts to “medicalizing normal grief.”² Indeed, we believe it begs the question-that is, assumes as true precisely what is in dispute-to suggest that someone who meets full symptom and duration criteria for MDE after a major loss merely “resembles” someone with a MDE. Nor do we believe that “grief reaction” is necessarily the right term for someone who meets full symptom and duration criteria for MDE, but who happens to present within two months of a major loss, including but not limited to the death of a loved one. 

And, while we take Dr Frances’s point that “…grief would become an extremely inviting target for the drug companies”², we believe that DSM5 criteria sets should be based on the best available science, not on predications regarding the behavior of pharmaceutical companies. Furthermore, by eliminating the bereavement exclusion, the DSM5 would bring its criteria for MDE in line with those of the International Classification of Disease, 10th edition (ICD-10). In the ICD-10, if Mr Jones meets criteria for a depressive episode-- notwithstanding the recent death of his wife-- he gets the diagnosis of depressive episode, subtyped as mild, moderate, or severe.⁴ We fully expect that this paradigm will continue in the ICD-11, now anticipated in 2014.  Harmonizing the DSM and ICD criteria is consistent with a goal advocated by Dr Frances himself.³ 

So what, in our view, does the best available science show? While acknowledging that definitive studies have yet to be done, we believe the best studies to date ^4-6 lead to the following conclusions:
1.      There are no convincing data that show depression in the context of loss to be fundamentally different than any other kind of depression, when full DSM symptom and duration MDD criteria are met.
2.    In contrast, there is evidence demonstrating that Bereavement-Related Depression (BRD) is similar to other instances of  depression occurring in the context of other major losses (job loss, divorce, etc.) in terms of risk factors, severity, associated features, patterns of co-morbidity, biology, course and treatment response.
3.      The current (DSM-IV) differentiating features for bereavement are not predictive of lower depression severity or risk.
4.   There are no convincing data showing that the bereavement exclusion for the diagnosis of major depression protects against “pathologizing” normal grief, or against over-diagnosing major depression.
5.     In contrast, it is not unlikely that the bereavement exclusion may lead, paradoxically, to keeping some severely depressed individuals who happen to be bereaved, or whose depressive episode was precipitated by death of a love one, from receiving much- needed treatment.
 
As we stated previously, we believe “…that continuing the bereavement exclusion in DSM5 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.”⁷

For example, in ordinary or “productive” grief⁸ and bereavement, the individual typically maintains her emotional connection with others; believes that the grief will end some day; maintains her self-esteem; and experiences positive feelings and memories along with painful ones. Guilt, if present, is focused on “letting down” the deceased person, rather than on being “worthless” or useless. In ordinary grief, loss of pleasure is related to longing for the deceased loved one, as opposed to the pervasive anhedonia often seen in severe depressions; and suicidal feelings are more related to longing for reunion with the deceased than to thoughts of not deserving to live.  Moreover, as Dr Kay R. Jamison has noted, in ordinary grief, an individual is capable of being “consoled” by friends, family, music, literature, etc.¹¹

In contrast to all this, in severe depression-particularly in the melancholic subtype-the individual tends to be extremely “self-focused”; feels outcast or alienated from friends and loved ones; has the sense that the depression will “never end”; experiences profound self-loathing and guilt; experiences few if any positive feelings or memories; and is often “inconsolable.” ^8-11      

We acknowledge that careful empirical investigation is required to confirm these largely observational findings; but we believe that the DSM5 text should include such phenomenological descriptors, even if the official criteria sets do not. In the mean time, we urge further investigation into both the biology and phenomenology of uncomplicated grief, complicated (pathological) grief, and MDD.⁸

In conclusion, we do not believe that elimination of the bereavement exclusion by itself will lead to the “medicalization” of grief; rather, we believe it will encourage those with potentially serious depressive illness, after recent loss, to seek help. Nor do we believe that elimination of the bereavement exclusion by itself will lead to over-medication, so long as clinicians are trained to apply DSM-5 criteria for MDE; to avoid premature prescription of antidepressants (eg, within the first week of depression); and to consider psychotherapy as the first-line treatment for short-lived, mild-to-moderate depression. To be sure, all this will require stepped-up training of both psychiatric and (especially) primary care physicians. 

Finally, we believe  it is time for the DSM to look more carefully at phenomenology-the contents of the patient’s felt experience-rather than relying almost entirely on behavioral and symptomatic check-lists.

References:

References

1.http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=427#

2.Frances A: Opening Pandora’s Box: The 19 Worst Suggestions For DSM5. http://www.psychiatrictimes.com/home/content/article/10168/1522341?pageNumber=2&verify=0

3.Frances A: A Warning Sign on the Road to DSM-V http://www.searchmedica.com/resource.html?rurl=http%3A%2F%2Fwww.psychiatrictimes.com%

2Fdsm%2Fcontent%2Farticle%2F10168%2F1425378%3FpageNumber%3D2&q=Frances+A.+A+Warning+Sign+on+the+Road+to+DSM-V%3A+Beware+of+Its+Unintended+Consequences.&c=ps&ss=psychTimesLink&p=Convera&fr=true&ds=0&srid=2

4.Zisook S, Kendler KS: Is bereavement-related depression different than non-bereavement-related depression. Psychological Medicine: 1-31, 2007

5. Zisook S, Shear K, Kendler K. Validity of the bereavement exclusion criterion for the diagnosis of major depressive episode. World Psychiatry. 2007 June; 6(2): 102–107. Accessed at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2219913/

6. Corruble E, Chouinard VA, Letierce A, et al. Is DSM-IV bereavement exclusion for major depressive episode relevant to severity and pattern of symptoms? A case-control, cross-sectional study. J Clin Psychiatry. 2009 Aug;70(8):1091-7.

7. Zisook S, Pies R. Letter, Psychiatric Times (response to Wakefield and Horwitz)http://www.psychiatrictimes.com/display/article/10168/1413394

8. Pies R. The anatomy of sorrow: a spiritual, phenomenological, and neurological perspective. Philos Ethics Humanit Med. 2008; 3: 17. Accessed at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442112/

9. Ghaemi SN. Feeling and time: the phenomenology of mood disorders, depressive realism, and existential psychotherapy. Schizophr Bull. 2007;33:122–30. 10. Zisook S, Shear K. Grief and bereavement: what psychiatrists need to know. World Psychiatry. 2009 June; 8(2): 67–74. Accessed at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2691160/

11.Jamison KR. Nothing Was the Same. New York, Knopf, 2009.