June 1st, 2014

Jury’s still out on omission of bereavement exclusion

One of the most controversial changes made last year was the removal of the “bereavement” exclusion from the major depressive disorder (MDD) diagnosis in DSM-5.

Proponents of the change argue that the removal does not “medicalize” grief, stigmatize bereaved individuals, imply that grief transforms into depression after two weeks or lead to un-necessary prescribing of anti-depressants.

Instead, they feel the elimination allows all people with MDD to receive care without ruling out the existence of interacting causes.

Opponents, however, believe the change was motivated by political and financial agendas, confuses grief and prolonged grief disorder with bereavement and is not evidence-based.

Ronald Pies, M.D., clinical professor of psychiatry at Tufts University School of Medicine, says that the DSM-5 does not declare anybody grieving a death after more than two weeks to have a mental illness. “This claim is flat out wrong and misleading,” he says. He notes that it instead removes the impediment to diagnosing major depressive disorder after bereavement only if the individual meets MDD’s full symptom severity and duration criteria at least two weeks following the death.

He says that it’s extremely rare for anyone with ordinary grief related to bereavement to seek professional help so quickly. If help is sought, Pies says, it is likely because a patient is referred by a worried family member or because the individual is suicidal or psychotic, in which case, the exclusion wouldn’t have applied using DSM-IV rules either.

Jill Colman, Psy.D., a Cambridge-based private practitioner specializing in grief for 15 years, initially was skeptical about omitting the bereavement exclusion, but now feels it is appropriate and sensible.

“I don’t live life by DSM. I use judgment,” Colman says, noting that she would refer a patient to a psychiatrist for medication when more aggressive treatment is needed based on the individual’s symptoms such as hopelessness, insomnia, overeating, etc.

She notes that a diagnosis would occur after ascertaining the “trajectory” of a patient’s condition and it’s up to a clinician to use caution and distinguish between the “ups and downs,” a grieving person experiences versus the continuous despair of depression. “Time teases out the differences,” Colman says. “One (visit) is not enough.”

Colman emphasizes that she agrees with the exclusion omission because it acknowledges that grief and a mental disorder can co-exist. She says that bereavement should not be excluded when other MDD causes such as a loss of job, cancer, a thyroid condition or other trauma are not.

“DSM-IV told clinicians not to diagnose depression in an individual within the first two months of death,” Colman says. “The exclusion suggested that grief protected someone from major depression. It doesn’t.”

Pies uses an analogy of a man having a heart attack after a giant grizzly bear appears suddenly in front of him. “Cardiologists do not say “Well, anybody would have a heart attack in a situation like that! This is just normal! Yet there are critics who say, in effect, ‘I can easily understand why Mrs. Jones would be depressed after her husband died. So this can’t be a disorder.’ In fact, Mrs. Jones may be grieving her husband and also have developed a major depressive episode.”

Pies says another reason the elimination was necessary is because major depression is “a potentially lethal disorder,” with a suicide rate of approximately 4 percent.

“Disqualifying a patient from a MDD diagnosis simply because the clinical picture emerges after the death of a loved one risks closing the door on potentially life-saving interventions,” he says.

Jerome Wakefield, DSW, Ph.D., a professor in the Silver School of Social Work at New York University, calls the suicide argument “nonsense,” pointing to research that concludes that individuals who are grieving have a lower chance of committing suicide than people in the regular population.

He calls other reasons given for the change in DSM-5 as “trumped up,” and motivated by a desire to “get reimbursement for helping people.”

Starting in 2007, Wakefield conducted research and supported a movement to extend the exclusion to milder depressive reactions to other stressors as well such as job loss, illness, divorce, etc. because the symptoms are identical.

“The research that my colleagues and I have continued to pursue and publish establishes beyond a doubt that the elimination of the bereavement exclusion was the wrong thing to do,” Wakefield says.

“Spurious,” diagnoses of depression can have numerous negative effects such as stigma and un-necessary treatment with antidepressants that brings with it side effects like muting positive as well as negative emotions and a difficulty to discontinue, he says.

No evidence exists that concludes major depressive disorder within two months of a significant loss persists unless treated or benefits from antidepressants, says Holly G. Prigerson, Ph.D., who has spent 20 years in this field of research.

Prigerson, who was an advisor to the DSM-5, is the Irving Sherwood Wright Professor of Medicine, professor of sociology in medicine and director of the Center for Research on Patients and Families Facing Serious Illness at Weill Cornell Medical College, New York Presbyterian Hospital.

She and former colleagues determined in the Yale Bereavement Study that most bereaved individuals begin the process of adapting to the loss by six months post loss. Those stuck in a state of chronic mourning meet the criteria for Prolonged Grief Disorder. Prigerson says she presented the data showing an empirical test of consensus criteria for PGD. Much of the information was put in the DSM-5 in the appendix as an area for future study. She points out that the ICD-11, on the other hand, will create PGD as a new disorder.

“DSM-5 blew it,” Prigerson says. “ICD-11 appears ahead of the DSM-5 curve.”

She calls the removal of the exclusion as a “power grab by big pharma and psychiatrists who have a financial conflict of interest” and says decisions made about DSM-5 were based on political and financial factors rather than evidence.

“It makes psychology look silly at best,” Prigerson says.

Wakefield says that not making a distinction for grief-related depression has practical implications for people including life insurance eligibility and cost, custody consideration in divorce proceedings and eligibility for certain jobs and a cancer drug trial offered by the National Institute of Health.

When presenting workshops on the DSM-5 to mental health professionals, Wakefield says the issue still prompts strong feelings. “This is one of the sources of frustration I hear: ‘how could they do something so stupid’?”

“Grief is tied to love and intimacy,” he adds. “Pathologizing it shows a wanton lack of respect for feelings. People regard this (omission) at a different level from other changes…It’s a topic that is just not going to go away.”

By Susan Gonsalves

One Response to Jury’s still out on omission of bereavement exclusion

  • June 3rd, 2014 at 5:31 pm Ronald Pies MD posted:

    I appreciate the citation of my comments in Ms. Gonsalves’ article.

    I appreciated Dr. Colman’s wise perspective on the need for clinical judgment in applying the DSM-5′s criteria for major depression. Clinicians will find the footnote on p. 161 of the DSM-5 manual helpful, with respect to distinguishing the “normal” grief of bereavement from major depression–though, as Dr. Colman correctly implies, grieving for a deceased loved one does not immunize the patient against a major depressive episode, and may actually precipitate one.

    If major depression is indeed present after bereavement, this does not necessarily mean that the patient will require antidepressant treatment, contrary to the fears of some critics of the DSM-5. Many mild-to-moderate major depressive episodes will respond to psychotherapy alone; episodes with profound impairment and/or melancholic features, however,may merit combined (medication and psychotherapy) treatment. Ordinary grief, of course, is not a disorder and requires no “treatment”, save love, support, and “tincture of time.”

    For a more detailed discussion of the rationale behind removing the bereavement exclusion, please see:

    http://psychcentral.com/blog/archives/2013/05/31/how-the-dsm-5-got-grief-bereavement-right/

    and:

    http://www.ncbi.nlm.nih.gov/pubmed/24042244

    Sincerely,
    Ronald Pies MD
    Professor of Psychiatry, SUNY Upstate Medical U.
    Clinical Professor of Psychiatry, Tufts USM

    Note: Dr. Pies is retired from clinical practice and reports no financial conflicts of interest with respect to this submission.

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