A Possible Compromise on Grief vs Depression


We can take one further step toward finding common ground in my ongoing debate with Drs Pies and Zisook.

We can take one further step toward finding common ground in my ongoing debate with Drs Pies and Zisook. Dr Pies has helpfully pointed the way in his latest piece

We agree that the problem is the fuzzy boundary between normal grief and Major Depressive Episode (MDE). It is at this mild end that our dispute lies. There is no dispute at the  severe end -- severe depressive symptoms during bereavement are already meant to be diagnosed as MDE using the current guidelines in DSM-IV-TR. So the test case is someone who has lost a spouse or child and has just 2 weeks of sadness and loss of interest, appetite, sleep, and energy. Such a person would have to be diagnosed with MDE if we were to follow the DSM-5 suggestion to simply remove the bereavement exclusion.
Dr Pies and I both disagree with the DSM-5 suggestion that 2 weeks is a long enough duration. There is no research suggesting that the distinction between normal grief and mild MDE can be reliably and validly made so early after the loss of a loved one in a griever with such mild and ubiquitous symptoms. This level of  mild symptoms for this short a duration occurring in the immediate aftermath of a loss are just too common and too compatible with normal grief to be considered MDE.

Dr Pies and I also agree that there is no need to medicate this griever having mild and completely expectable symptoms for so short a period. We would both instead recommend a combination of commiseration, empathy, support, and watchful waiting to see if the person goes on to have  a normal evolution of grief (most will) or goes on to have enduring or more severe symptoms compatible with MDE.
Dr Pies worries more than I do that the current DSM-IV-TR criteria are too stringent and create a  false negative problem-- ie, missing MDE during bereavement and witholding appropriate treatment from those who need it. He would make it easier to get an MDE diagnosis during bereavement than is currently possible using DSM-IV-TR, but would require  much more stringent standards for its diagnosis than are being suggested for DSM-5. Dr Pies suggests a 1 month duration (not 2 weeks) and perhaps a higher threshold of symptom severity.

Dr Pies' suggestions are a reasonable way to balance the risks of false negatives vs false positives. I worry much more than he does about false positive overdiagnosis and overtreatment. So I would prefer to stay where we are, but I could not strongly disagree with the Pies/Zisook suggestion. I would add to it just two exclusions. The diagnosis of MDE may be inappropriate if the individual's culture calls for a more profound expression of grief or if the individual has a personal history of a deep, but self limited, grief in the past.
So, where do we continue to disagree? I believe that to remove the bereavement exclusion for MDE would disastrously open the floodgates to the misdiagnosis and overtreatment of normal grief  (especially by hurried primary care physicians who do much of the prescribing). To me, the DSM-5 suggestion, as it stands now simply doesn't fly at all and is a public health threat. In contrast, Dr Pies is willing to hold his nose and swallow a DSM-5 suggestion that he acknowledges will confuse grief with MDE. He invokes the image of saved suicides to defend his persevering effort to not miss any MDE patient, regardless of the negative consequences.

I analyze the benefits and risks of the DSM-5 proposal quite differently. I don't see much benefit because I don't think the current rules result in many missed cases. DSM-IV-TR already allows extremely wide play for clinical judgment in deciding between grief and MDE. A clinician is welcomed to make an MDE diagnosis whenever he or she believes the specific circumstances warrant it-- even with relatively mild symptoms in a grieving person (say, someone who has had previous depressions or previous prolonged grief). If the grief symptoms are severe, DSM-IV-TR insists that MDE be diagnosed. Clinicians do not find impediments to the appropriate diagnosis under the current system. It is an unproven and unlikely red herring that the DSM-5 change will save lives (or for that matter have any beneficial effect at all).    

But, as detailed in several previous posts, I believe the risks of the suggested change are great. I won't go through all the specific arguments yet again, but DSM-5 is promoting a needless expansion of psychiatric diagnosis that would reduce the dignity of grief, create insurance and job stigma, and result in unnecessary, expensive, and potentially harmful treatment. 

There is no proven efficacy for medication treatment given after just 2 weeks of mild symptoms in grievers. My guess is that the placebo response rates would be so high in this population that no active medication efficacy could ever be demonstrated. But medications do have side effects (including increasing suicidal symptoms in some people).

My suggestion to Pies/Zisook is to not give up the fight with DSM-5 for an appropriate 1 month duration requirement for milder MDE-- if not in all situations (my choice and theirs) then at least for MDE during bereavement. Swallowing a spoiled half loaf can be bad for the nation's health. We can assume that drug advertising to patients and marketing to doctors will result in a flood of treatment that they would also question. This should worry Pies/Zisook more than it does and stiffen their resolve to fight the good fight (with an admittedly unreasonable DSM-5) to require a 1 month duration of symptoms.

So let's be clear about a reasonable compromise. Reasonable people can disagree about the precise duration requirement before grief can be considered mild depression. Pies/Zisook suggest 1 month. I am OK with the DSM-IV-TR 2 months. Some people think it should be longer. No one but DSM-5 is suggesting 2 weeks-- which seems like a really bad idea.

This ongoing Talmudic debate with Pies/Zisook has been fruitful. A similarly careful risk/benefit analysis should be, but is not, occurring for all of the many questionable DSM-5 proposals.

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