the rabbit hole…

Posted on Tuesday 26 March 2013

There’s a thread here that deserves to be tied together. The topic is the Bereavement Exclusion that the DSM-5 Task Force removed from the diagnosis of Major Depressive Disorder [DSM-IV]:
    E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
It’s a peculiar deletion  because the stated clinical reason for removing it makes little sense – something like reminding clinicians that for some, Bereavement triggers a Major Depression. So why not just say that? Since when is a Diagnosis a post-it note reminder, as if we wouldn’t notice a Major Depression? Kenneth Kendler, speaking for the Task Force adds:
    … a broad range of evidence agreed to by both sides of this debate show s 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… 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.
He’s referring to research by Jerome Wakefield et al from 2007:
Extending the bereavement exclusion for major depression to other losses: evidence from the National Comorbidity Survey.
by Wakefield JC, Schmitz MF, First MB, and Horwitz AV
Archives of General Psychiatry. 2007 64[4]:433-40.

CONTEXT: Symptoms of intense bereavement-related sadness may resemble those of major depressive disorder [MDD] but may not indicate a mental disorder. To avert false-positive diagnoses, DSM criteria for MDD exclude uncomplicated bereavement of brief duration and modest severity. However, the DSM does not similarly exempt depressive reactions to other losses, even when they are uncomplicated in duration and severity.
OBJECTIVE: To test the validity of the DSM exclusion of uncomplicated depressive symptoms only in response to bereavement but not in response to other losses.
DESIGN: Community-based epidemiological study
PARTICIPANTS: From the National Comorbidity Survey [NCS] of 8098 persons aged 15 to 54 years representative of the US population, we identified individuals who met MDD symptom criteria and whose MDD episodes were triggered by either bereavement [n = 157] or other loss [n = 710].
INTERVENTION: We divided the bereavement and other loss trigger groups into uncomplicated and complicated cases by applying the NCS algorithm for uncomplicated bereavement to the reactions to other losses. We then compared uncomplicated bereavement and uncomplicated reactions to other losses on a variety of disorder indicators and symptoms.
MAIN OUTCOME MEASURES: Nine disorder indicators, as follows: number of symptoms, melancholic depression, suicide attempt, duration of symptoms, interference with life, recurrence, and 3 service use variables.
RESULTS: Episodes of uncomplicated depression triggered by bereavement and by other loss have similar symptom profiles and are not significantly different for 8 of 9 disorder indicators. Moreover, uncomplicated reactions, whether triggered by bereavement or other loss, are significantly lower than complicated reactions on almost all disorder indicators
CONCLUSION: The NCS data do not support the validity of uniquely excluding uncomplicated bereavement but not uncomplicated reactions to other losses from MDD diagnosis.
however, Wakefield positioned himself on the other side of the debate:
After Removal from DSM-5, Why Clinicians Should Remember the Bereavement Exclusion
by Jerome C. Wakefield, PhD, DSW
Psychiatry Weekly. 8[4] February 18, 2013
[full text online]

After undergoing its first major overhaul in nearly 20 years, the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is slated for a May 2013 release. Of the many changes in DSM-5, one of the most controversial is the removal of the DSM-IV’s “bereavement exclusion” (BE) to major depressive disorder (MDD), which allows clinicians to defer making a clinical diagnosis of MDD when certain depressive symptoms occur within the context of recent bereavement and do not last more than 2 months. Under this exception, such an episode is classified as a “V-code,” signifying the absence of mental illness…

Dr. Wakefield’s research indicates that the BE’s rules have much to recommend them. He finds that uncomplicated bereavement-related—or other stressor-related—depressive syndromes generally have markedly lower levels of pathological features than complicated or endogenous/psychotic depressions.1,2 Also, uncomplicated depressions do not recur like other depressions; persons who experience a single episode of uncomplicated bereavement-related depression are no more likely to have a recurring depressive episode by 3-year follow-up than persons with no lifetime history of depression.

“In light of solid evidence that uncomplicated bereavement-related depression is similar to uncomplicated reactions to other stressors, I and other researchers suggested expanding the BE in DSM-5 to apply to uncomplicated stressor-related depressions generally,” says Dr. Wakefield. “However, extension of the BE was rejected out of hand. Instead, based on the similarity evidence, the DSM-5 Mood Disorders Work Group argued that bereavement is not special, so the BE should be eliminated. This latter argument ultimately won the day”…

This more properly frames the recent paper by Gordon Parker [see in the range of a mandate…]. After discussing the significant qualitative differences between grief and depression [phenomenology, natural course, staging, and treatment response], Parker argues:
    … And so Pandora’s box is further opened. Rather than drawing bereavement within the domain of the clinical depressive disorders (as DSM-5 appears still to favour), we might better lean the other way and consider whether many currently positioned clinical depressive disorders (especially the reactive depressive conditions) might fit more comfortably within a grief paradigm, and benefit more from management weighting such a model.

    Many have put a reductionist view that grief is completely normative and depression is always clinical, and that any merging will ensure a wide-scale move to manage bereaved people with psychotropic medication. To be fair, DSM-5 is likely to be addressing a reality – that some bereaved individuals will develop a clinical depressive episode – and that their treatment might then involve a differing management paradigm to that for normative grief. However, the recent DSM-5 annotation or website note appears underpinned by Kendler’s observation that the DSM-IV grief exclusion criterion is ‘not logically defensible’. This essay seeks to broaden the list of logical parameters that invite consideration. In particular, it invites weighting of phenomenological distinction between grief and depression, and consideration of an alternate paradigm that allows some reactive depressive disorders to be more logically modeled and managed as ‘grief’ states.
In the comments, Bernard Carroll elaborates further on that theme:
    The DSMs never did lay claim to phenomenological subtlety, and the bereavement exclusion never was the exception that proved the rule. Rather it was the sad little secret that outed DSM-III Major Depressive Disorder [MDD] as a sham. The bereavement exclusion allowed the notion of process to get a foot in the door, countermanding a simple listing of symptoms as the way to understand clinical disorders. The DSM-5 folks are hoist on the petard of generic MDD. If the reference disorder MDD disallows considerations of process, then of course the bereavement exclusion must go. Gordon Parker’s discussion turns Kenneth Kendler’s position on its head and sensibly argues for extension of the grief model to other reactive dysphoric states.

And just as a reminder, here’s one more reference for the road:

DSM II  [1968]

300.4 Depressive neurosis
This disorder is manifested by an excessive reaction of depression due to an internal conflict or to an identifiable event such as the loss of a love object or cherished possession. It is to be distinguished from Involutional melancholia and Manic-depressive illness. Reactive depressions or Depressive reactions are to be classified here.

So the debate about removing the Bereavement Exclusion is more fundamental than just the issue of pathologizing normality [which is in itself pretty important]. It also reopens the problem created when the various depressive diagnoses were inappropriately lumped as Major Depressive Disorder in 1980 for the DSM-III. I’ll skip over the stated reasons as I don’t believe they were central [see a mistake…, further thoughts on the mistake…, yet another mistake…]. There seemed to be two related agendas in that change: removing psychoanalytic formulations from psychiatry and convincing third party carriers that we were scientists treating medical diseases, not life problems. Both were successful. The collateral damage was removing Melancholia – the classic psychiatric disease that was a major target for biological research. An unintended consequence was creating a mythical disorder [MDD] that became prime real estate for the pharmaceutical industry, corrupted science, and rampant overmedication. Another consequence was moving most practicing psychiatrists to the role of medication managers.

I suppose one could see this issue of reactive depressions as an  inconvenient truth that has haunted psychiatry throughout the last three decades. The Bereavement Exclusion is a portal like the rabbit hole in Alice in Wonderland that leads to a place where the current frame of reference no longer makes any sense, and calls for "consideration of an alternate paradigm that allows some reactive depressive disorders to be more logically modeled and managed as ‘grief’ states." Eliminating the Bereavement Exclusion from the code book hasn’t succeeded in maintaining the status quo so far, nor is it likely to after the book is released in a couple of months. In fact, though the DSM-5 Task Force set out to effect a paradigm shift to a biological diagnostic system, it looks as if the only shift they’ve created is a shift away from the DSM-5 itself as the diagnostic standard…
    March 26, 2013 | 1:43 PM

    So, if a person’s four year-old child dies from cancer, they have two months to pull it together or risk having an indelible label affixed to them and might possibly be told that they have to be on medication for life, because (ostensibly) all their previous functioning had just been masking their MDD?

    Death isn’t an icon. Grief isn’t a symptom. The fact that one’s world might demand that one never be overwhelmed with feelings that get in the way of working 9 to 5 does not mean that a person who does get overwhelmed is mentally ill. By that logic, sociopaths are the picture of mental wellness.

    Should a grieving person want to be numb for awhile, I wouldn’t argue. It’s their choice, and for many it can be a choice between being numb and working, or being out in the streets with all feelings intact; but meds can be described without having to define a person by the medication that is being prescribed for them, can’t they? Isn’t that the advantage of having “reactive” ahead of “depression” and “psychosis” when a person is in a state that is no way typical for them and is experiencing profound grief or stress?

    March 26, 2013 | 3:55 PM

    “Many have put a reductionist view that grief is completely normative and depression is always clinical, and that any merging will ensure a wide-scale move to manage bereaved people with psychotropic medication.” In my opinion, there is already wide scale management of the bereaved with psychotropic medication, often by primary care docs who usually offer it the very first thing when made aware of catastrophic loss. And then, even if the bereaved person has the strength to refuse the meds, there is often constant pressure to “try them” if the patient still reports feeling sad or depressed in the future. So, finally, the person relents and then finds they’ve started a med they can’t stop even when they want to.

    March 26, 2013 | 5:21 PM

    Re: the rabbit hole

    (Alice falls down the rabbit hole)
    Alice: Well, after this I should think nothing of falling down stairs.

    White Rabbit: [singing] I’m late / I’m late / For a very important date. / No time to say “Hello, Goodbye”. / I’m late, I’m late, I’m late.

    Alice: If I had a world of my own, everything would be nonsense. Nothing would be what it is because everything would be what it isn’t. And contrary-wise; what it is it wouldn’t be, and what it wouldn’t be, it would. You see?

    I reads like ‘Alice in Wonderland’.


    March 26, 2013 | 9:54 PM

    I never had a problem with the “Depressive Neurosis” diagnosis; it properly distinguished melancholia, likely heavily biologically-determined, from mood drops due to the slings and arrows of current life interacting with prior (childhood) insults (real or fantasized). Boy, we have sure sacrificed a lot in our determined effort to keep Freud buried! I think the push back against DSM-5 will one day be seen as a “return of the repressed.” LOL.

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