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.
Moving ForwardAfter 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.
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.
"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."
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.