Posted on Wednesday 27 February 2013

Getting Past the Grief over Grief
Scientific American
By Sidney Zisook
February 25, 2013

These days, I get a lot of grief about grief. I am part of the work group that changed some of the ways that grief and clinical depression are described and differentiated in the new Diagnostic and Statistical Manual of Mental Disorders, typically referred to as DSM-5. That has led to a lot of conversations with colleagues who are upset about bereavement. The other day, a friend and fellow psychiatrist—whose son had died by suicide almost a year ago—took me aside to tell me how incensed he was about the elimination from earlier DSMs of language specifying a “bereavement exclusion.” The “exclusion” essentially detailed a two-month period of “normal grief” that people would experience after the loss of a loved one. During this period, it was all but forbidden to diagnose a patient with major depression—even if the individual had all the symptoms [which are, in important and sometimes life-threatening ways, different from grief.]

This restriction was based on the best science from the mid-1980s, the last time DSM was fully revised, but the science of bereavement and major depressive disorder has changed. Our work group found the exclusion too limiting; normal grief often lasts much longer than two months, and a small subset of patients can have major depression triggered or exacerbated by a loved one’s death, just as they can from all kinds of losses and traumas. But critics have convinced a lot of people that our goal was to diagnose every grieving person with major depressive disorder. It especially pained me to hear my friend say, “How dare they label me with depression, as though I should have been over my grief months ago? How dare they imply I should take medications to drown my sorrow?” He missed his son intensely long after his death, thought about him frequently, and continued to experience waves of intense anguish and yearning for his son’s return. He felt like a piece of him was missing and that it would never be found. He had occasional problems sleeping through the night, difficulty watching some of the TV shows he and his son had enjoyed so much together. And he had yet to return to playing golf, which the two of them had also shared. He was fully back to work and seeing patients, but he couldn’t help worrying more than in the past when caring for potentially suicidal young people.

Despite his anger, he readily accepted my hug, my offer to take him to lunch and my eagerness to listen. I told him how sorry I was for his loss, that it was impossible for me to imagine how difficult it had been for him and his wife, and that I thought his continued grief was perfectly understandable—and in no way indicative of major depression. Like most people after a loss, he needed comfort, not treatment. We agreed to meet at a later time to talk about the bereavement exclusion. It was a fascinating discussion. I made it clear to him that the elimination of the bereavement exclusion in no way, shape or form dictates how intense his grief should be or how long it should last. His feelings were absolutely normal. I also stressed how dropping the exclusion does not re-label grief as major depression, nor does it medicalize grief. That is not to suggest that grief is not “depressing.” For many people, grief is very depressing, if by that you mean feeling sad, blue and down in the dumps. But those emotions are not the same as having a major depressive disorder, a serious clinical condition that certainly is not part of normal grief.

Our work group changed the grief language in DSM-5 to make sure clinicians and patients understand that major depression can occur in someone who is bereaved, just as it can occur in someone who is going through a divorce, facing a sudden disability or terminal illness, or struggling with serious financial troubles. There are no known clinically meaningful differences in the severity, course or treatment response of major depressive episodes that occur after the death of a loved one compared to those occurring in any other context. According to the best research available, any very stressful life event can trigger a major depressive episode in a vulnerable person; regardless of the context in which it occurs, prompt recognition and appropriate treatment can be life-promoting and even life-saving.

In addition, eliminating the bereavement exclusion in no way suggests that intense grief should be treated. Just the opposite. It makes clear, for the first time, how to spot and properly diagnose those individuals in whom major depression is triggered by the death of a relative or close friend —which is the same way we diagnose everyone else. And treatment with medications is by no means automatic or the only option. In some cases, education and support during a period of “watchful waiting”  may be the most appropriate intervention; in other cases—for example, when the person has had previous bouts of serious depression, or when the major depressive episode is particularly severe and persistent—more formal treatments with evidence-based psychotherapies and/or medications might be the best option.

My friend and I discussed how these changes might affect primary care physicians, who write most of the prescriptions for antidepressants and so, technically, diagnose most depressions. One of the main concerns voiced was that the bereavement exclusion, however clumsy and unscientific, was the only thing keeping some family physicians from “giving every grieving patient an antidepressant after a 10-minute evaluation!” But we both agreed that the criteria for major depression should not be jiggered so as to anticipate poor practice by other clinicians. Instead, psychiatrists must provide more training and consultation to the other treatment professionals who might see grieving patients.

By the time our lunch ended, my friend’s view had softened.  As we talked about the difference between his extended grief and a major depressive disorder, he said that it maybe was time for him to look into a suicide survivors support group. He even allowed that, given his knowledge of the potential consequences of untreated major depression, he would assess a bereaved individual who met the diagnostic criteria in the same careful way he would any other patient. We again hugged, and then we both headed back to work. In the end, we agreed: It is time to stop grieving the loss of the bereavement exclusion.

A diagnostic system is intended to be a scientific collection of illnesses grouped in a variety of ways. At its best, the conditions would be described as syndromes that defined an illness of known etiology – leading a clinician directly to a conclusion that might direct treatment. At the very best, there would be pathognomonic findings that are only found in one disease – the rash on the palms and soles in syphilis, petechial hemorrhages at the base of the hair follicles in Scurvy, thinning of the lateral eyebrows in Myxedema, etc. While it may lead to specific treatment planning, a diagnostic system is not a treatment manual.

In the first highlighted paragraph, Dr. Zisook says that he needs to teach clinicians that Major Depression can be triggered by grief. In the second highlighted paragraph, he says the system can’t be adjusted for bad clinical practices. Those two things are mutually exclusive. He wants to be sure we treat depressed people, but he doesn’t want to be sure we don’t overtreat grieving people. And, by the way, since when is a diagnostic manual a treatment directive? His notion that his opinion about treatment matters is on the arrogant side, but more to the point, it’s not what he was hired to do. And also by the way, his uncontrolled study of a handful of grieving people treated with Wellbutrin is hardly compelling.

"It is time to stop grieving the loss of the bereavement exclusion." That’s not how grief works. Grief isn’t something you stop. It’s something that has a course and often results in change – usually for the better. It makes us aware of what really matters in life. In this case, the loss of the bereavement exclusion makes us aware of the triviality of the DSM-5’s exclusive focus on mood and altering it rather than on our patient’s humanity and development.
    February 27, 2013 | 1:34 PM

    The APA ‘publish first – patch later’ approach to science:

    Joel E Dimsdale, MD to ABC News: “If it doesn’t work, we’ll fix it in the DSM-5.1 or DSM-6.”

    “New Psych Disorder Could Mislabel Sick as Mentally Ill”

    Feb. 27, 2013

    Bernard Carroll
    February 27, 2013 | 10:01 PM

    As far as I know, the study of bupropion (Wellbutrin) in major depression post bereavement is the only evidence Dr. Zisook brings forward for his claim of successfully treating such patients. To call his uncontrolled study hardly compelling is a charitable understatement. It is a laughable study. It was sponsored by the drug’s manufacturer, for whom Dr. Zisook also gave paid speeches. It was uncontrolled, so much of the reported improvement would be expected had there been a placebo treated comparison group. There were no self report depression measures, so we don’t know whether the patients also thought they had improved in terms of major depression. Their self reported grief scores improved, but once again we have no comparison group, and the natural course is for improvement.

    But most of all, it was a tiny study in a skewed population – they enrolled fewer than 1% of the subjects they invited to participate (22 out of 3998, to be exact, or 0.55%). It is impermissible to generalize from this miniscule sample in order to make broad policy for DSM-5
    Dr. Zisook glossed over the fact that many people he would give a hug to, like his friend, do indeed meet the nominal criteria for major depression, as Paula Clayton taught us decades ago, even while we acknowledge that their grieving is a normal process. In other words, there are many false positive diagnoses of major depression among the bereaved. Dr. Zisook doesn’t explain how he identifies the ones who need more than a hug.

    February 27, 2013 | 11:57 PM


    You left out commenting on this comment Dr. Ronald Pies on the Scientific American Blog Post:

    Which includes:
    “The fear that the entirely understandable grief of bereavement will be “inappropriately diagnosed” as major depressive disorder(MDD)has never been borne out, to my knowledge, in any published research studies of actual patients.”

    Is this true?

    “Furthermore, the risk of completed suicide in MDD (approximately 4 in 100) far outweighs the risk of “over-diagnosing” normal grief as major depression”

    How good is the evidence that labeling people with major depressive disorder and delivering the treatments that typically come along with that label leads to a significant reduction in completed suicide rates?

    What I find most confusing in Dr. Ronald Pies comments comes in this paragraph:
    “Contrary to a popular misconception, there are indeed substantial differences between “ordinary” or “normal” grief associated with loss, and MDD. For example, bereaved persons with normal grief often experience a mixture of sadness and more pleasant emotions, as they recall memories of the deceased. Anguish and pain are usually experienced in “waves” or “pangs,” rather than continuously, as is usually true in major depression. The normally grieving individual typically maintains the hope that things will get better. In contrast, the clinically depressed patient’s mood is almost uniformly one of gloom, despair, and hopelessness–nearly all day, nearly every day. The bereaved individual usually maintains a strong emotional connection with friends and family, and often can be consoled by them. The person suffering a severe major depressive disorder is usually too self-focused and emotionally “cut off” to enjoy the company of others. Indeed, Dr. Kay R. Jamison has pointed out that “The capacity to be consoled is a consequential distinction between grief and depression.”

    So, even if we take what Dr. Pies describes about grief at face value we would have an individual who could experience anguish and pain in “waves.” Presumably this could occur for most of the day for at least 2 weeks during the period after a loss. They can remain hopeful. Which of the DSM Major Depressive Disorder criteria are clearly precluded by the presence of hopefulness? They have the ability to be consoled. Which of the DSM Major Depressive Disorder criteria are clearly precluded by the presence of being able to be consoled. If the ability to be consoled is supposed to be a consequential distinction then is there any implication in the DSM that Major Depressive Disorder is not supposed to be diagnosed if the individual is capable of experiencing consolation from family members?

    1BOM, I hope that you comment directly on Dr. Pie’s commentary. I am not doing it justice. By which I mean that I am either not adequately understanding his argument in this paragraph, because to my reading it does not seem to have much with the DSM diagnostic system as actually written, and am thus not doing it justice. Or I am adequately understanding it, in which case I am not sufficiently excoriating it.

    Please help out either way with a follow-up post if you have the time.

    February 28, 2013 | 12:23 AM

    Because it almost seems like he is saying that there are ways one can distinguish depression and grief, but the diagnostic manual has not seen fit to include them. Again, what am I substantively missing? Because the argument he is making would be absurd if that is a correct understanding.

    February 28, 2013 | 8:01 AM

    I still just don’t get how “treatment” helps the bereaved. One close friend is on an SSRI and was definitely pressured to take it by her primary care physician. She reports that it just makes her feel “numb”. She has even attempted to stop it yet. This is four years after the death of her daughter. I would guess she’s been taking the SSRI at least two years. Two other friends, widowed in 2008, were given SSRIs by their primary doctor and they now report they’ve been unable to stop when they’ve tried: and both have. Both almost five years later. Wonder if my “study” is as valid as Dr. Zisook’s??

    February 28, 2013 | 8:57 AM

    Thank you BOM. Many things remain unanswered to my satisfaction. And, we have a duty to help protect the one vulnerable against what has the potential to be systemic harm foisted on the bereaved.

    February 28, 2013 | 11:38 AM

    Decisions like the above by the APA are just another example of why private practice psychiatry is going to be basically gone by 2016.

    I’ll post the various reasons by Friday, most that are not new or surprising.

    What is surprising is how so many psychiatrists not only agree to their own demise, but make the lethal brew, drink it willingly, and dug their own graves with fairly much no help. Shame the powers that be can’t make these fools bury themselves to minimize further labor.

    berit bj
    February 28, 2013 | 12:09 PM

    “How is your (recently widowed) father-in-law?” “He’s fine, thank you. He’s crying a lot.”
    The speaker was David Kvaebek, a respected psychotherapist at Modum Bad in Norway. at a time when a stiff upper lip was expected, especially of men.
    In some cultures the bereaved are assisted by professonal mourners, who beat their breasts and cry loudly.
    Who would tell what is best or right or not normal grief? A vote by a committee of APA’s selfappointed psychiatrists, many of whom have ties to Big Pharma?

    February 28, 2013 | 8:07 PM

    Don’t try to make sense out of anything written by Ron Pies.

    February 28, 2013 | 8:33 PM

    ~ 3 Months later ~

    At the APA:

    Staff: “Well, we’re all taking antidepressants to medicate our grief about losing the bereavement exclusion. A lot of us are getting pretty worried about our rampant polypharmacy now”

    Dr. Zisook: “It’s time we stop worrying about polypharmacy, here, add some xanex.”

    March 1, 2013 | 3:20 AM

    Peggi, I am so sorry to hear about your friends having difficulty in stopping SSRIs. Have they tried tapering very slowly like, 5 to 10% of current dose every 4 to 6 weeks?

    If they haven’t and are interested in learning more, they might want to visit the Surviving Antidepressants website which is not beholden to any commercial interests and depends totally on financial donations.

    In other words, many people have difficulty getting off because the tapering schedule is way too fast. I was able to get off of 4 psych meds tapering at this slow rate.

Sorry, the comment form is closed at this time.