1 Boring Old Man

By Kenneth S. Kendler, M.D.: Member, DSM-5 Mood Disorder Work Group

Misconceptions about the proposal to eliminate the grief exclusion criterion from DSM-IV have been presented online and in the media. Writers have expressed fear that the change will lead to automatic diagnosis of individuals who are grieving with Major Depressive Disorder. I would like to provide some background on the grief exclusion and some insight into thinking behind the proposal to remove it for DSM-5 in order to put this change into perspective.

First, the grief exclusion criterion – which states that someone who has experienced a recent bereavement is not eligible for a diagnosis of major depression – was not present in the two major psychiatric diagnostic systems that formed the basis for the DSM-III – the diagnostic manual that is the immediate precursor of our current DSM-IV. Rather, it was added to DSM-III largely on the basis of the work of one of the DSM-III task force members who was then studying grief and was carried forward with little modification into DSM-IV. Second, the other major psychiatric diagnostic system used in the world – the International Classification of Diseases – has never had a grief exclusion criterion for major depression.

Third, a broad range of evidence agreed to by both sides of this debate shows that there are little to no systematic differences between individuals who develop a major depression in response to bereavement and in response to other severe stressors – such as being physical assaulted and raped, being betrayed by a trusted spouse whom you learn has been unfaithful or a beloved child whom you are told is dealing drugs, having your doctor tell you that your breast or prostate biopsy for cancer is positive or the loss of your treasured job. So the DSM-IV position is not logically defensible. Either the grief exclusion criterion needs to be eliminated or extended so that no depression that arises in the setting of adversity would be diagnosable. This latter approach would represent as major shift, unsupported by a range of scientific evidence, in the nature of our concept of depression as epidemiologic studies show that the majority of individuals develop major depression in the setting of psychosocial adversity.

Fourth, the vast majority of individuals exposed to grief and to these other terrible misfortunes do not develop major depression. That does not mean, and here is the source of much confusion, that they do not grieve. They do. It does not mean that they do not feel terrible pain and loneliness. They do. Depression is a slippery word and we are so used to using it to mean “sad”, “blue”, “upset” or, in this specific case, “grieving.” Major depression – the diagnostic term – is something quite different. Finally, diagnosis in psychiatry as in the rest of medicine provides the possibility but by no means the requirement that treatment be initiated. Watchful waiting is important tool for all skilled clinicians. As a good internist might adopt a watch and wait attitude toward a diagnosable upper respiratory infection assuming that it is unlikely to progress to a pneumonia, so a good psychiatrist, on seeing an individual with major depression after bereavement, would start with a diagnostic evaluation.

If the criteria for major depression are met, then he or she would then have the opportunity to assess whether a conservative watch and wait approach is indicated or whether, because of suicidal ideation, major role impairment or a substantial clinical worsening the benefits of treatment outweigh the limitations. As with the psychiatric response to the other major stressors to which we humans are all too frequently exposed, good clinical care involves first doing no harm, and second intervening only when both our clinical experience and good scientific evidence suggests that treatment is needed.

• "there are little to no systematic differences between individuals who develop a major depression in response to bereavement and in response to other severe stressors"
• "epidemiologic studies show that the majority of individuals develop major depression in the setting of psychosocial adversity"
• "the vast majority of individuals exposed to grief and to these other terrible misfortunes do not develop major depression"

since: most depressed people have major psychosial stressors of similar magnitude to a significant interpersonal loss
and
since: there’s no clinical difference between the bereaved and the otherwise stressed
ergo: grief is not unique so the exclusion needs to be removed.

since: "the vast majority of individuals exposed to breavement and to these other terrible misfortunes do not develop major depression"
ergo: there is a kind of person that develops clinical depression in response to psychosocial stressors
and
since: "epidemiologic studies show that the majority of individuals develop major depression in the setting of psychosocial adversity"
ergo: there is a kind of person [in the minority] with clinical depression that doesn’t have psychosocial stressors
ergo: In this way of interpreting the clinical information, there are three kinds of people:
• people who are neither clinically depressed nor become clinically depressed in the face of psychosocial adversity [most] [normal]
• people who have developed clinical depression in the face of psychosocial adversity [some] [exogenous depression]
• people who have developed clinical depression without a history of psychosocial adversity [few] [endogenous depression]

My point is that ever since the DSM-III was a gleam in Robert Spitzer’s eye, people have been howling about the lumping of all depression into one great big category. Many articles in our current literature call MDD a "heterogeneous" group and explain the wimpy responses to medications or the brisk response to placebos on that basis. We’ve had thirty years of lumping but the people who study depression still talk about Melancholia as a unique depression, including the DSM framers who concede a "with" in our criteria. Even people who are solidly Biological/DSMers like Dr. Alan Schatzberg [who defends the DSM-5 revision] has focused his fame and fortune on "psychotic depression" as a unique entity.

My take on all of this is that Dr. Kendler is the one with the "misconception" about why there’s so much alarm about removing the bereavement exclusion in the DSM-5. It’s about something other than what he responds to in the statement reproduced here. The category Major Depressive Disorder cries out for revision sure enough. It’s probably the most "revisable" category in the whole manual. But it needs to be carefully fractionated rather than broadened further. The thought that the only thing his work group can think of to do with their last ten years is piddle with the exclusion clause when the main category needs a long overdue overhaul is simply infuriating.

So we’re left to speculate why. Are they afraid the psychoanalysts and psychotherapists will raise their ugly heads and suggest that the kind of people who develop clinical depression in response to stressors will suggest a mind/personality explanation again? I can set his mind to rest. We still think that way after thirty years. When I see a depressed person, I take a history first off, and a family history, and a history of previous stresses, etc. And what I learn has a lot to do with my diagnostic formulation and what I recommend. He doesn’t have to worry that I’m going to try to take over the APA because I think that way. I get it that my ancestors made a mistake putting psychoanalysis into the DSM-II. Point taken. But the DSMs also have hampered research on the "endogenous depressions" by lumping them into oblivion. What most of us suspect is that they won’t seriously revise the DSM Depression category because it will decrease the target population for the clinical trials and the medications, putting a damper on the current biological/medication fervor in psychiatry. That’s a legitimate concern. It would likely have that effect. And for a thousand other reasons, a damper on the current biological/medication fervor in psychiatry might be the best thing to happen in the last thirty years. But that’s not my reason for being infuriated by the behavior of the DSM depression work group.

My reason is that they’re not doing their jobs…