in this case…

Posted on Saturday 21 September 2013

Remember the DSM-5? the controversy over removing the Bereavement Exclusion?
by Zisook S, Pies R, and Iglewicz A.
Journal of Psychiatric Practice. 2013 19:386-396.

Based on a review of the best available evidence and the importance of providing clinicians an opportunity to ensure that patients and their families receive the appropriate diagnosis and the correct intervention without necessarily being constrained by a somewhat arbitrary 2-month period of time, the DSM-5 Task Force recommended eliminating the "bereavement exclusion" [BE] from the diagnosis of major depressive disorder. This article reviews the initial rationale for creating a BE in DSM-III, reasons for not carrying the BE into DSM-5, and sources of continued controversy. The authors argue that removing the BE does not "medicalize" or "pathologize" grief, "stigmatize" bereaved persons, imply that grief morphs into depression after 2 weeks, place any time limit on grieving, or imply that antidepressant medications should be prescribed. Rather, eliminating the BE opens the door to the same careful attention that any person suffering from major depressive disorder deserves and allows the clinician to provide appropriate education, support, hope, care, and treatment.
the article ends with:
Moving Forward
After the death of a loved one, grief almost always occurs, often accompanied by sadness, loneliness, and other features of dysphoria. Acute grief is a difficult, emotionally taxing process that often lasts much longer than 2 months, whether or not there is a co- occurring MDD. And, like other very stressful life events, the death of a loved one may precipitate a full MDE in a vulnerable person. When this happens, the MDE generally appears soon after the loss as an unwelcome companion to the bereaved’s grief. The individual then faces the double burden of grief and MDE. The major rationale for removing the BE was to remove a roadblock to diagnosing MDD, a serious, highly recurrent, potentially fatal disorder, regardless of its apparent cause or precipitant.  Diagnosing MDD does not “medicalize” or “pathologize” grief, nor does it “stigmatize” the bereaved person, imply that grief morphs into depression after 2 weeks, or place a time limit on grieving. Nor does diagnosing MDD in the context of bereavement imply that antidepressant medication should be immediately prescribed. Rather, eliminating the BE opens the door to the same careful attention that any person suffering from MDD deserves, and it allows the clinician to provide appropriate education, support, hope, care, and treatment. We recognize that clinical judgment — even when guided by the most “evidence-based” diagnostic criteria — is not infallible, and mistakes will be made. But we believe that the risks to the patient of “missing” MDD are far greater than the risks of being given a diagnosis of MDD and drawn into the mental health treatment milieu, even if the diagnosis ultimately proves to be “wrong” over the ensuing weeks. It is time for proponents of both sides of the BE argument to collaborate in learning more about grief and MDD — their commonalities and their differences — so that we may better serve those in need.
What was all of that about – that endless debate about the Bereavement Exclusion? Was it a discussion about something that mattered? or a battleground for some other issue? In retrospect, does the march of the DSM manuals mean anything at all?

The relationship between depression, loss, and grief has long been noted and a source of some of the more important theorizing about the human condition and relationships. A general assumption is that what we call grief is the expected human response to a loss of some kind, most intense when the loss involves someone of personal importance. The psychoanalysts postulated that grief and depression were intimately related, the latter being the result of a loss in fantasy rather than fact. Other psychological theories about grief pointed to its usual course, and looked on the fact that some people developed protracted symptoms as a disruption of normal processes. Cognitive theorists, noting that depressed people have a particular type of cognition, applied learning and behavioral techniques to the problem – a cognitive behavioral approach.

There is another thread in the story of depression reaching into antiquity. There are people who become periodically depressed independent of life experiences. The classic version is melancholia which has physiological changes suggesting a physical origin. It occurs is single episodes or a recurrent form, and may be accompanied by episodes of mania – the classic Manic Depressive illness described by Emil Kraepelin often with a family history suggesting a genetic cast to the illness. Kurt Schneider proposed the terms Endogenous Depression for this group of illnesses and Reactive Depression for those related to the personality or life events.

As a new trainee, I never questioned that distinction. The clinical differences were striking to me, though like many before me, I explored the history of this second group, but it never went anywhere – the depression had a life of its own. I didn’t realize that this difference was matched by a deep divide in psychiatry itself until later when the DSM-III rewrote that distinction by creating a unitary category called Major Depressive Disorder. The forces at work have been rehashed endlessly here and everywhere else in the ensuing three decades. On the surface, the reason given was that the evidence for that distinction was weak or speculative. Not very far under the surface was the feeling that physicians should stick with matters medical, more biological. But that solution generated a new problem, identifying the whole domain of symptomatic depressed people as targets for biologic therapy – yet another topic rehashed endlessly here and everywhere else.

Personally, I only vaguely knew about the Bereavement Exclusion in Major Depressive Disorder – because MDD never made it into my understanding of depression. When I came across a case of melancholic depression, I referred the person to experts. In turn, many of them referred me cases from the other group. My concept of protracted grief was likewise unchanged by those manuals which I treated as code books rather than textbooks. So, in my case, the controversy over the Bereavement Exclusion in Major Depressive Disorder came down to the symbolic – it was one of the few places where the manuals conceded non-biological causes of mental discomfort. For others, the controversy was more concrete – based on the facts.

All of that is a long introduction to my personal take of Zisook’s article above which focuses on two of his comments, comments that clarified for me why I had such a negative visceral reaction to the DSM-5 process:
  • "The major rationale for removing the BE was to remove a roadblock to diagnosing MDD, a serious, highly recurrent, potentially fatal disorder, regardless of its apparent cause or precipitant."
  • "But we believe that the risks to the patient of “missing” MDD are far greater than the risks of being given a diagnosis of MDD and drawn into the mental health treatment milieu, even if the diagnosis ultimately proves to be “wrong” over the ensuing weeks."
The first comment seemed fanciful on first reading. Dr. Zisook apparently thinks that practitioners see the DSM-anything as something like dogma and might withhold treatment or other measures because of something it says – confusing a code book with a papal decree. It seemed an odd comment, and an odd position to come from the APA. But the second comment drew more emotion. His "we believe" is way beyond something that belongs in a diagnostic manual. He apparently does think that his opinion rises to the level of dogma. Worse, he’s basing the category itself in this supposedly evidence based manual not on some consensus derived from the evidence, but on the implications of the diagnostic criteria. He’s directing clinical decisions by altering diagnostic criteria, or at least trying. And as I fumed about that, it dawned on me that that kind of manipulation underlies a lot of the DSM decisions – including the original choice to create MDD in the first place.

When I step back from all of this, I realize that the framers of the DSM-III had an agenda to remove psychoanalysis and other psychologizing from psychiatry for a variety of reasons. That goal was achieved and has long been a settled matter. But I’m now thinking that their method of reaching that goal by changing the DSM-III has had some long-lasting consequences with significant collateral damage. One example is creating a fiction, MDD, that has contributed heavily to the collusion with PHARMA, a standstill in focused depression research, and the current overmedication problems. But this article by Zisook may be another example. It assumes that the DSM defines not only mental illnesses but also directs treatment. The Bereavement Exclusion was no "roadblock." There are few people I know that worry about "’missing’ MDD." I don’t actually know many people who see MDD as a discrete entity anyway. Nor do I know any people who will "miss" it when it’s finally gone.

But it’s not his opinion that I’m decrying here, it’s the fact that he thinks that this opinion is so important that it should be encoded in a diagnostic manual. One of the major criticisms of psychiatry is elevating opinion to the level of fact. In this case, that it is a valid criticism…
  1.  
    September 21, 2013 | 12:27 PM
     

    Zisook: “But we believe that the risks to the patient of “missing” MDD are far greater than the risks of being given a diagnosis of MDD and drawn into the mental health treatment milieu, even if the diagnosis ultimately proves to be “wrong” over the ensuing weeks.”

    And that explains why more than 10% of the US population over the age of 12 is taking antidepressants, most of them unnecessarily, and for many years.

    The point is, anyone going to an MD in a tearful state will get a prescription for an antidepressant, and that’s fine with Zisook and his friends at the APA — because they want to STAMP OUT DEPRESSION no matter what it takes.

    If stamping out depression means accidentally stamping out the personalities and sex lives of millions who get false positive pseudo-diagnoses, so what — the spice must flow! The mission must go on!

  2.  
    CannotSay2013
    September 21, 2013 | 12:35 PM
     

    Mickey,

    I assure I don’t imply any offense here either. I think you are a soul full of doubts who can be saved for the good cause. I fully understand that it is not easy to realize that the endeavor in which one has invested so much is a fraud. I can only think as an analogy a Catholic priests who discovers in his 80s that Jesus bones were found, thus refuting the whole Resurrection narrative.

    You say,

    “One of the major criticisms of psychiatry is elevating opinion to the level of fact. In this case, that it is a valid criticism… ”

    This is very ironic coming from somebody who just yesterday wrote a very offensive post calling for easing the civil commitment laws basing his whole argument in his “sixth sense” to detect dangerous people.

    Mickey, you can be saved for the good cause. It is never too late.

  3.  
    Steve Lucas
    September 21, 2013 | 2:05 PM
     

    This post reminded me that when mental health assistance was added to my wife’s insurance she immediately started receiving letter asking if she felt sad or frustrated at work. Government employees at all level feel sad and frustrated. Political appointees who are more interested in process than product and serving a desired clientele make it almost impossible for the best concepts to be run effectively.

    There were no treatment goals in these letters, only the financial gain of maximizing someone’s insurance.

    Steve Lucas

  4.  
    wiley
    September 21, 2013 | 4:37 PM
     

    A lot of intelligent people are convinced that “mental illness” is biological and that medication works. They believe that the most severely mentally ill people are being helped the most.

    How many people who were suffering from life’s pains have been convinced that they have a medical illness and that it was a drug and not time that made them feel better?

    Most intelligent people believe that the biological banner lessens stigma. These people think that they are informed by science. How can this be turned around? Surely some people have benefited from medication some times and I want people to have that option with fully informed consent; but as long as most educated people believe the hype the odds that the strictly biological model would be dismantled look sleight to me.

  5.  
    CannotSay2013
    September 21, 2013 | 5:18 PM
     

    wiley,

    There are reasons to be optimistic. This documentary is from 1967 https://www.youtube.com/watch?v=-AXAOT_swIE . Around 1:23 you have a psychiatrist bashing homosexuals in the same way today’s psychiatrists bash people labelled as “schizophrenic” or “bipolar”, also warning of the “dangerous” consequences of leaving so called “homosexuality” untreated. Guess what, 45 years later, gay marriage is legal in several US states and at the federal level.

    Mickey, and the like, waste no time every time there is a mass shooting caused by a so called “mentally ill” on psychiatric drugs to call for ever increasing powers to abuse people.

    But they have a problem. There is increased visibility to experiences like Eleanor Longden’s https://www.youtube.com/watch?v=syjEN3peCJw that show that such threats are unwarranted. In fact, Eleanor’s experience, or the experience by these people http://openparadigmproject.com/, show that rejecting mainstream psychiatry is the way to a very fulfilling life.

    Just as not every homosexual is a pedophile, not every voice hearer, or person who thinks in non conventional ways, is an Aaron Alexis. The message is getting out fast to the point that I agree with the voices that say that DSM 5 might be the last edition of the book of insults.

  6.  
    September 21, 2013 | 5:50 PM
     

    Wiley.

    From where I sit, slight is a major step in the right direction. It was formerly less than zero. I’m optimistic that the forces for a more honest and credible science are building within the ranks of medicine and psychiatry. I think that it’s already true that what has gone on in the past decades couldn’t be repeated, and that the game now is focused on insuring a better future. There’s an old blues song, “been down so long it looks like up to me.” It doesn’t feel that way to me anymore.

  7.  
    wiley
    September 21, 2013 | 6:03 PM
     

    Well, Mickey, I hope you’re right. What actually worries me the most is our unscrupulous press and the power of money. What worries me a little is the national habit of 180 reversals that deftly avoid a deeper understanding of any complex issue by turning everything into a black and white issue.

  8.  
    Steve Lucas
    September 21, 2013 | 6:07 PM
     

    A topic we are touching on is treatment and that starts with diagnosis. My personal belief is that GP’s pushing pills that have little use at the beginning and may in fact become toxic after time does a disservice to all involved, especially the patient. The only winner is pharma.

    My wife’s sister with an art degree and decades at home decided to return to school and pursued an art therapy degree. She spent time in nursing homes as part of her program, but was unable to find work in that area. Instead she ended up with a county wide program and after just a few months had clients with appointments, and was running a number of group sessions. This is in no way a criticism of her but of a system that does not properly screen patients, nor does it treat their problems in a professional manner.

    Instead we have a reliance on medication and the resulting polypharmacy is treated as simply a part of the patient’s psychosis. The insurance limitations to push these people out of the program and combined with the inability to place them in a supervised setting means they will return. Worse yet are those that commit a violent act and end up in jail, or prison, where they will receive no help or those who end up dead.

    We need a better system where those few, very few, who need supervision receive that supervision, not just more meds. Those who need counseling receive counseling, and no meds, and a system that does not seek financial gain from loosely defined protocols.

    What we have now is a system where the least qualified treat those with the most severe problems and the predictable results are a mess where the patient and society suffers. We collectively bear an unbelievable cost financially and in terms of human tragedy. This system needs to be changed.

    Steve Lucas

  9.  
    TinCanRobot
    September 21, 2013 | 6:18 PM
     

    That reminded me of an article I read some time ago, about 2 DSM5 board members who resigned and dissented.
    http://www.psychologytoday.com/blog/dsm5-in-distress/201207/two-who-resigned-dsm-5-explain-why

    The DSM5 board could argue about things that aren’t even real, like ‘treatment resistent depression” just as if it was Thors Hammer in a comic book shop. Truely scary.

  10.  
    a-non
    September 21, 2013 | 6:29 PM
     

    “There is another thread in the story of depression reaching into antiquity. There are people who become periodically depressed independent of life experiences. The classic version is melancholia which has physiological changes suggesting a physical origin.” Mickey

    I’m hoping that road is followed:
    http://evolutionarypsychiatry.blogspot.com/2013/08/pathophysiology-of-depression-and.html

  11.  
    September 21, 2013 | 9:49 PM
     

    Sorry, I see that Ronald Pies is one of the authors of the above, and frankly, after a long week of BS and other lame political crap per PPACA stupidity, this comment reflects Dr Pies’ endless garbage in selling grief as depression:

    He is an idiot, and as long as he continues to align himself with this failed agenda, well, I hope he crashes and burns when his failure is complete. What a loser this doctor has become. I hope he either reads this comment or finds out about it from others, I look forward to reading his lame defense of his position further. Grief is not inherently depression.

    Sorry Mickey, but it needs said, these authors advising for treating grief as depression, go F— yourselves!!!!

  12.  
    Florence
    September 22, 2013 | 12:57 AM
     

    Some good news for the day. The American Psychiatric Association is recommending a great reduction in neuroleptics for children and the elderly. They are also recommending more judicious use of only one neuroleptic at a time rather than the recent neuroleptic cocktails of two or more of these toxic drugs. They are warning that using these drugs for insomnia is inappropriate since they aren’t good for this use, which would be great for soldiers. They are also recommending very close monitoring of these dangerous drugs.

    I thought this article was appropriate here since these lethal drugs are being pushed for everything now including depression. See Abilify ads.

    http://www.psychiatry.org/choosingwisely

  13.  
    Florence
    September 22, 2013 | 1:01 AM
     

    Could lawsuits like the one for off-label use of Seroquel for insomnia causing tardive dyskinesia below be part of the incentive for reducing the growing absurd use of these toxic drugs off label and for many other so called mental illnesses?

    http://www.courthousenews.com/2013/09/20/61327.htm

  14.  
    Richard Noll
    September 22, 2013 | 8:31 AM
     

    In my classes in recent years I’ve emphasized a close reading of the PTSD section of DSM-IV. We follow its historical path since 1980 from the Dissociative Disorders to the Anxiety Disorders and now, with DSM-5, to traum and stress related disorders. We chew over the meaning of the term “trauma” and explore the ways in which it can (and has been) stretched. We explore the observation that there are individual differences in the ways in which people respond to trauma and look at what little is known about resilience and so forth.

    One additional issue we explore is that of natural (not just complicated) grief/bereavement and how, if one reads the PTSD section carefully, it could easily be subsumed under the PTSD diagnostic criteria. It has always struck me as interesting that elite discourse pins grief/bereavemet exclusion debate within the domain of MDD. I have my suspicions as to why this has always been so, but will remain in an inarticulate state for the moment until I have a few more cups of coffee and perhaps hear the thoughts of some of you about this.

  15.  
    wiley
    September 22, 2013 | 11:23 AM
     

    I’m looking forward to hearing your thoughts, Richard.

  16.  
    Tom
    September 22, 2013 | 12:03 PM
     

    I have often thought that conversion disorder has many similarities to PTSD.

  17.  
    September 22, 2013 | 12:58 PM
     

    Thanks, Florence. Could it be the APA is shifting to concern for patient safety????

    From http://www.psychiatry.org/choosingwisely

    APA’s list includes the following five recommendations:

    - Don’t prescribe antipsychotic medications to patients for any indication without appropriate initial evaluation and appropriate ongoing monitoring.
    - Don’t routinely prescribe two or more antipsychotic medications concurrently.
    - Don’t prescribe antipsychotic medications as a first-line intervention to treat behavioral and psychological symptoms of dementia.
    - Don’t routinely prescribe antipsychotic medications as a first-line intervention for insomnia in adults.
    - Don’t routinely prescribe antipsychotic medications as a first-line intervention for children and adolescents for any diagnosis other than psychotic disorders.

    (I agree with Joel Hassman about Ron Pies.)

  18.  
    CannotSay2013
    September 22, 2013 | 4:03 PM
     

    Altosatrata,

    “Florence. Could it be the APA is shifting to concern for patient safety”

    :D. I think that you have a too high view of psychiatrists and the APA in general. If so called “patient safety” was a concern, then they would stop ECT altogether, and stop recommending SSRIs as first line of so called “treatment” for anything for which placebo intensive therapies (like CBT) work.

    I see this announcement as a combination of pressure from many fronts:

    1- Psychiatry under attack by its own ranks (Insel recently also echoed Whtiakers points on neuroleptics) in a way it hasn’t been in 40 years.

    2- The media at large amplifying 1-. http://www.madinamerica.com/2013/09/behind-amazing-victory-mental-health-activists-robert-whitaker/ .

    3- The internet uniting victims of psychiatric abuse. I, for one, would not have been able to connect with other psychiatric survivors this way 15 years ago.

    This is no different from when the APA dropped homosexuality from the DSM. It was not “science”, it was increasing lobbying power by those targeted by a “homosexuality” label. It seems the APA never learns the lesson. When the target of their invented labels (or in this case medication agenda) is a significant part of the population, the dynamics change. For the APA (and the psychiatric profession) to be successful, the target of their hate has to be a small portion of the population unable to fight back. Each crisis in psychiatry has been caused by psychiatry pushing the boundaries of what is acceptable from the civil liberties point of view too hard.

  19.  
    September 22, 2013 | 5:00 PM
     

    I am sure the APA cares not a whit about anything Robert Whitaker might say or anything that’s published on MadinAmerica.

    Most likely their concern about appropriate antipsychotic prescription comes from Medicaid studies showing excessive use in youth and nursing home populations, for which the government is balking at paying.

  20.  
    TinCanRobot
    September 22, 2013 | 5:28 PM
     

    I couldn’t imagine the APA being concerned about patient saftey. Not just from a historical point of view, but their current president Dr. Lieberman denies that so much as any conflict of interest even exists. “That was then, and this is now”.

    If the APA isn’t addressing rampent criminal activity, kickbacks, bribes, muti-billion dollar fines for Felony illegal marketing and fraud convictions, data manipulation fraud cases, etc. etc.

    It’s pretty unlikely the lines added to the DSM5 were anything more then ass covering. When the goverment investigated though the GAO into childhood overprescription for antipsychotic drugs the APA had to respond somehow. Afterall, they bascially added ‘temper tantrums’ as a new disorder to the DSM5 and that’ll probably increase prescriptions anyway. Why else add another code for insurance reimbursement?

  21.  
    CannotSay2013
    September 22, 2013 | 5:40 PM
     

    Altostrata/TinCanRobot,

    I hadn’t thought about that economic angle, but you guys are probably right. Uncle Sam saying “enough” to this corporate welfare is a much stronger argument than concern for patients or survivors activism, although the latter surely helped those interested in decreasing Medicaid/Medicare payments make their case. Something like: look, even those who “allegedly” benefit from these drugs say the whole thing is baloney, let’s give a try at decreasing this massive drugging and we save some bucks along the way :D.

  22.  
    a-non
    September 23, 2013 | 11:26 AM
     

    Welcome to the political use of psychiatry?
    “An audience member at a lecture by Georgi Morozov on forensic psychiatry in the Serbsky Institute asked, “Tell us, Georgi Vasilevich, what is actually the diagnosis of sluggish schizophrenia?”[19] Since the question was asked ironically Morozov replied ironically: “You know, dear colleagues, this is a very peculiar disease. There are not delusional disorders, there are not hallucinations, but there is schizophrenia!”
    https://en.wikipedia.org/wiki/Sluggishly_progressing_schizophrenia

  23.  
    a-non
    September 23, 2013 | 11:56 AM
     

    From Labtimes:
    “The implication seems to be that as long as researchers can pass off their mistakes as sloppiness, rather than intentional misconduct, they should be forgiven and carry on their work. We’re with that logic, to a point; after all, we’ve argued before that due process is much too important, no matter how apparently damning the evidence is. And as long as corrections and retraction notices are detailed, telling the whole story, science and the public are served.”
    http://www.labtimes.org/labtimes/ranking/dont/2013_05.lasso

  24.  
    September 23, 2013 | 8:43 PM
     

    Thank you altostrata, for your comment about agreeing with me about Dr Pies, but the process to the content I made in my comment was out of line.

    I am tired of people focused on partisan agendas, not principles that support and defend the needs of the public, at least as a physician. I am burnt out listening to people who claim to lead and represent, but their deeds are only about maintaining their own status among their alleged peers and the public, maintaing their status woe that benefits them and their cronies financially first and foremost, and doing whatever humanly possible to crush dissent, legitimate or not in argument.

    I think we are witnessing the most pervasive and efficient infiltration of characterological discord in positions of power across the planet, much less here in the US, and people affected as a sizeable majority don’t care about the ramifications.

    Laugh and or dismiss me off. If I am wrong, I guess we are all happy for my mistake. If I am right, well, who is then happy? Not me. Look around and pay attention to who is happy.

    Sorry for the tone of my earlier comment, but not the basic content. Defending grief as really depression is wrong. Period.

    Noting depression can come from complicated bereavement, no argument here. Is the APA creating a liability by setting such a precedence by this book?

    I have no legal expertise to offer opinion. Yeah , you read that last sentence right! But, I clamor for accountability in the poor judgment by the APA. They want to run the show, well, are they prepared for possible consequences if wrong!?

  25.  
    September 24, 2013 | 2:10 PM
     

    Well, Joel, you put it very crudely, but all I could come up with was parallel euphemisms to characterize Dr. Pies.

    We don’t always agree, but it is obvious you are outraged at the corrosion of your profession, and I appreciate that.

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