In case it’s not apparent, I’m trying to get my remaining thoughts about the DSM-5 said, so as to put it away and move on in the New Year. I’ll think I’m done with it, then I’ll read something like the recent Washington Post article
, and it gets me all stirred up again [see Howard Brody’s comments
]. In my post
about that article, I looked at an article by Zisook et al
, a small uncontrolled trial of Wellbutrin in bereavement. And the WaPo article mentioned Zisook’s involvement with the DSM-5 Task Force:
A key adviser to the committee — he wrote the scientific justification for the change — was the lead author of the 2001 study on Wellbutrin, sponsored by GlaxoWellcome, showing that its antidepressant Wellbutrin could be used to treat bereavement…
So I looked up Zisook’s articles
on grief and found 37 papers spanning over thirty years, focusing on the Bereavement Exclusion since 2007. Something seemed odd about that, and stuck with me. Then I remembered what it was. The formal rationale for dropping the Bereavement Exclusion from the Major Depressive Disorder posted on the DSM-5 website wasn’t written by Dr. Zisook, it was written by Kenneth S. Kendler, M.D.: Member, DSM-5 Mood Disorder Work Group
. The logic of Kendler’s explanation gave me a headache when I read it a year ago [depressing ergo-mania…
]. Then I noticed the obvious, that Drs. Zisook and Kendler were co-authors on many of those articles. This was all beginning to feel like a campaign:
Since the publication of DSM-III in 1980, the official position of American psychiatry has been that the presence of bereavement is an exclusion criterion for the diagnosis of a major depressive episode (MDE). However, the empirical validity of this exclusion has not been well established. As DSM-V is now being planned, it is timely to reexamine the bereavement exclusion, particularly in the light of new evidence since the last reviews of this subject. This paper evaluates the relative validity of two competing hypotheses: 1) the bereavement exclusion for the diagnosis of MDE is not valid because, using validating criteria, bereavement related depression (BRD) within the first two months after the death of a loved one resembles non-bereavement related depression (SMD); 2) the bereavement exclusion for the diagnosis of MDD is valid because, using validating criteria, BRD within the first two months after the death of a loved one does not resemble SMD. The prevailing evidence more strongly supports Hypothesis 1 than Hypothesis 2. Thus, the bereavement exclusion for the diagnosis of MDE may no longer be justified.
Objective: Of the stressful life events influencing risk for major depression, DSM-III and DSM-IV assign a special status to bereavement. A depressive episode that is bereavement-related and has clinical features and course characteristic of normal grief is not diagnosed as major depression. This study evaluates the empirical validity of this exclusion criterion.
Method: To determine the similarities of bereavement-related depression and depression related to other stressful life events, the authors identified and compared cases on a range of validators in a large-population-based sample of twins. The authors evaluated whether cases of bereavement-related depression that also met DSM criteria for “normal grief” were qualitatively distinct from other depressive cases.
Results: Eighty-two individuals with confirmed bereavement-related depression and 224 with confirmed depression related to other stressful life events were identified. The two groups did not differ in age at onset of major depression, number of prior episodes, duration of index episode, number of endorsed “A criteria,” risk for future episodes, pattern of comorbidity, levels of extraversion, risk for major depression in their co-twin, or the proportion meeting criteria for “normal grief.” However, individuals with bereavement-related depression were slightly older, and more likely to be female, and had lower levels of neuroticism, treatment-seeking, and guilt and higher levels of fatigue and loss of interest. Interaction analyses failed to find unique features of people whose illness met criteria for both bereavement-related depression and normal grief compared to those whose illness was related to other life stressors.
Conclusions: The similarities between bereavement-related depression and depression related to other stressful life events substantially outweigh their differences. These results question the validity of the bereavement exclusion for the diagnosis of major depression.
The South is in a hard freeze and grey. It’s a great time for building a big fire and watching some old British Inspector Morse mysteries from a set I got as a present, or talking to friends who wander by, equally shut in by the cold. All this musing about The Bereavement Exclusion was in the spaces in between. It’s the holidays after all, a time to loll about after the busy·ness of Christmas Present. That last article was still on my screen when I came down from last night’s long winter’s nap. And as I scanned it, I realized that I felt angry [in the range of very angry]…
There have been many different objections to removing the Bereavement Exclusion from the DSM-5. It pathologizes normal people and medicalizes a human problem. Of course, it feels a lot like yet another ploy to give people even more medications [because it is]. Likewise, it sure fits Dr. Frances’ complaint that the Task Force was focused on pet projects of its members, in this case the pet project from San Diego, rather than some serious effort at revising the Manual. What makes it more ludicrous is that Major Depressive Disorder is the most glaring of the lot in it’s need to be revised. And all the Mood Disorders Work Group can find to do with their time is rationalize away the Bereavement Exclusion? Talk about mangled priorities! But that’s not what made me angry [in the range of very angry]:
And so I went into full rant prevention mode. We went to the store and bought the ingredients for tonight’s dinner with a friend and her kids-home-from-college. I took an old man nap, woke up and loaded the Bread Machine. Then I went outside to feel the bright winter sun that arrived while I was asleep. I even brought in the wood for tonight’s fire [I’m not without my resources when in full rant prevention mode]…
For thirty years, the majority of my psychiatric career, I’ve been a good sport. I’ve listened while psychotherapy, psychodynamics, psychoanalysis have been maligned and I’ve tried to separate the straw man arguments from the ones that were right and learn from latter. I left academics and practiced quietly during the Decade of the Brain, the Age of Prozac, and the Clinical Neuroscience years. And I kept my mouth shut until I realized that many in the upper levels of psychiatry had flat sold out to the pharmaceutical industry and become drug reps in white coats with big words, publishing a lot of trash. And even then I’ve tried to keep my ad hominems limited to the really bad guys. I haven’t even gone off on the ones who speculate so wildly based on questionable observations to retaliate for their endless accusations aimed at people like me for doing that very thing in the past. I’ve even held my tongue on this question of depression and grief when they leave out the exquisite body of research on attachment, separation, loss, and depression as if it were never recorded. I’ve been restrained given the circumstances. But then I read this:
Interaction analyses failed to find unique features of people whose illness met criteria for both bereavement-related depression and normal grief compared to those whose illness was related to other life stressors… The similarities between bereavement-related depression and depression related to other stressful life events substantially outweigh their differences. These results question the validity of the bereavement exclusion for the diagnosis of major depression.
So depressed people and grieving people look the same. Nothing new there:
The distinguishing mental features of melancholia are a profoundly painful dejection, cessation of interest in the outside world, loss of the capacity to love, inhibition of all activity, and a lowering of the self-regarding feelings to a degree that finds utterance in self-reproaches and self-revilings, and culminates in a delusional expectation of punishment. This picture becomes a little more intelligible when we consider that, with one exception, the same traits are met with in mourning. The disturbance of self-regard is absent in mourning; but otherwise the features are the same.
Mourning and Melancholia, Sigmund Freud 1917
But it’s not even that it’s old hat – it’s the conclusions they reach from their study. They took a large sample of twins who met the criteria for Major Depressive Disorder and divided them into groups based on whether they had bereavement-related depression
or depression related to other stressful life events
. They looked pretty much the same, so they concluded that the Bereavement Exclusion needs to be dispensed with and they should all be folded into the category Major Depressive Disorder:
Uh Oh. Red Alert. Full rant not yet prevented. Time to soften the peppers and onions for supper. Slow cook the sausages. Press some garlic. Get the butter out of the fridge. See how the bread is coming along. Maybe even check on the afternoon position of the solar disk.
In a medical model, the point of making a diagnosis is to evaluate signs and symptoms, obtain other studies if needed, all aimed at finding a CAUSE. For many conditions where the CAUSE is not known, the point is to locate a known SYNDROME, however CAUSE always trumps SYNDROME. So a person with shortness of breath, swollen feet, and an enlarged heart and liver has the SYNDROME of congestive heart failure. If you hear a characteristic diastolic murmer, the CAUSE is likely Mitral Valve Stenosis and the likely cause of that is Rheumatic Heart Disease. If there’s no murmur, and the blood pressure has been chronically very high, the likely CAUSE is Hypertensive Cardiovascular Disease. etc.
In this case, Kendler, Myers, and Zisook describe paired groups of twins who meet the DSM-IV criteria for Major Depressive Disorder. One group has had a significant recent loss. The other group has some other significant recent life stressor. So in this case, Major Depressive Disorder is a SYNDROME. There are now two CAUSES on the table, easily distinguished by asking very simple questions: "Have you sustained a significant loss recently? anyone close to you died?" "Are you under any particular stress right now?" But the SYNDROME of Major Depressive Disorder contains many other possibilities: Melancholia, a Depressive Episode in the course of Manic Depressive Illness, a number of medical or neurological conditions with defined CAUSES, etc. Melancholia and a Depressive Episode in the course of Manic Depressive Illness are IDIOPATHIC Diseases [defined diseases of unknown CAUSE].
Rant feelings ascending. Rest period. Go make coffee. Watch the sun come up. Let the feelings pass. Clean up the kitchen from last night’s dinner. Take out the garbage…
That wasn’t the reason. The reason was that the psychoanalysts were seen as dominating psychiatry and had to go. The commonest diagnosis was Depressive Neurosis
, too Freudian for the DSM-III’s agenda of eliminating psychoanalytic coincepts from psychiatry and its diagnostic system. Dr. Spitzer was afraid that any category like depression related to other stressful life events
would leave the door open for some version of Depressive Neurosis
– so the many different faces of depression were thrown together as Major Depressive Disorder, stated clearly by historian Dr. Edward Shorter in Before Prozac
"Bottom Line: Major Depression doesn’t exist in Nature. A political process in psychiatry created it…"
This succeeded is sending the analysts packing, at least as a major force in psychiatry. Part of the reason for eliminating the psychoanalysts was that the third party payers were no longer willing to pay for either psychoanalysis or psychiatrists doing psychodynamic psychotherapy. Treatments were long; outcomes unmeasurable; diagnoses somewhat irrelevant; initiated by choice rather than clear need; based on theories derived by individual analysts from individual patients, then generalized; and so on and so on. We all know the reasons. But the solution had enormous unintended consequences [I hope they were unintended]. Rather than Major Depressive Disorder narrowing the domain of psychiatry to matters biological, or presumed biological, or treatable biologically, it held on to those formerly-known-as-depressive-neurosis patients with bereavement-related depression, depression related to other stressful life events as targets for the pharmaceutical industry and the psychiatrists who joined with the pharmaceutical industry. While they could apparently get away with folding depression related to other stressful life events in with Melancholia, a Depressive Episode in the course of Manic Depressive Illness, or a number of medical or neurological conditions with defined CAUSES, etc., they couldn’t pull it off with bereavement-related depression, ergo the inclusion of the Bereavement Exclusion ["the bastion of sanity in a cloud of politics" – author unknown].
Whoops. Now I’m making up things too. I said that bastion thing, not some unknown author. Obviously, it’s time for another break.
Midday New Years Eve…
They got it backwards, Kendler, Myers, and Zisook, and for that matter, the DSM-5 Task Force. The fact that bereavement-related depression
and depression related to other stressful life events
look the same means they both
need to be removed from the diagnostic category [SYNDROME
] Major Depressive Disorder. Their CAUSES
are known. The fact that they interpreted their results as meaning the Bereavement Exclusion needs to be abolished is a telling, and very discouraging. To me it means that they have come to see the DSM-III, DSM-IV, and now DSM-5 definition of Major Depressive Disorder as a sacrosanct entity unto itself rather that just a list made at some point in history for reasons having to do with an anachronistic political squabble within psychiatry. They’ve confused the signifier with the signified. And I can assure them that in 2012, the psychoanalysts are not lurking in the background scheming to take over psychiatry. You have my word on it.
The discouraging part is that the Mood Disorders Group was tasked to revise the DSM-IV category, Major Depressive Disorder [the part most in need of a facelift, with a partitioning of the many syndromes that are locked within its remarkably broad boundaries]. Instead, their only suggestion was to remove one of the few definitions that makes sense. Removing the Bereavement Exclusion, a pet project, is symptomatic of a much deeper problem – a failure to really understand the basic point of medical diagnosis. Any comment about the why of it would be speculative, but whatever the why, the what is absurd.
I’d like to say that my New Year’s Resolution is to no longer talk about the DSM-5, but I doubt that it would be kept. I think instead I’ll resolve to have no more two day long posts with a running internal rant prevention dialog included…
An early version misplaced Dr. Kendler at UCSD. He is at Virginia Commonwealth University, writing with Dr.Zisook at UCSD.