1 Boring Old Man

Grief Could Join List of Disorders
New York Times
By BENEDICT CAREY
January 24, 2012

In a bitter skirmish over the definition of depression, a new report contends that a proposed change to the diagnosis would characterize grieving as a disorder and greatly increase the number of people treated for it. The criteria for depression are being reviewed by the American Psychiatric Association, which is finishing work on the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., the first since 1994. The manual is the standard reference for the field, shaping treatment and insurance decisions, and its revisions will affect the lives of millions of people for years to come…

The new report, by psychiatric researchers from Columbia and New York Universities, argues that the current definition of depression — which excludes bereavement, the usual grieving after the loss of a loved one — is far more accurate. If the “bereavement exclusion” is eliminated, they say, “there is the potential for considerable false-positive diagnosis and unnecessary treatment of grief-stricken persons.” Drugs for depression can have side effects, including low sex drive and sleeping problems. But experts who support the new definition say sometimes grieving people need help. “Depression can and does occur in the wake of bereavement, it can be severe and debilitating, and calling it by any other name is doing a disservice to people who may require more careful attention,” said Dr. Sidney Zisook, a psychiatrist at the University of California, San Diego…

Under the current criteria, a depression diagnosis requires that a person have five of nine symptoms — which include sleeping problems, a feeling of worthlessness and a loss of concentration — for two weeks or more. The criteria make an explicit exception for normal grieving, which can look like depression. But the proposed diagnosis of depression has no such exclusion, and in the new study, Jerome C. Wakefield of New York University and Dr. Michael First of Columbia concluded that the evidence was not strong enough to support the change. “An estimated 8 to 10 million people lose a loved one every year, and something like a third to a half of them suffer depressive symptoms for up to month afterward,” said Dr. Wakefield, author of “The Loss of Sadness.” “This would pathologize them for behavior previously thought to be normal.”

But Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh School of Medicine and the chairman of the task force making revisions, disagreed, saying, “If someone is suffering from severe depression symptoms one or two months after a loss or a death, and I can’t make a diagnosis of depression — well, that is not being clinically proactive. That person may then not get the treatment they need”…

Getting the diagnosis increases the likelihood of being treated for what is normal behavior, or close enough. Task force members argue differently: if a person is in distress and seeking help, then treatment ought to be offered — and covered by insurance…

By Kenneth S. Kendler, M.D.: Member, DSM-5 Mood Disorder Work Group

Misconceptions about the proposal to eliminate the grief exclusion criterion from DSM-IV have been presented online and in the media. Writers have expressed fear that the change will lead to automatic diagnosis of individuals who are grieving with Major Depressive Disorder. I would like to provide some background on the grief exclusion and some insight into thinking behind the proposal to remove it for DSM-5 in order to put this change into perspective.

First, the grief exclusion criterion – which states that someone who has experienced a recent bereavement is not eligible for a diagnosis of major depression – was not present in the two major psychiatric diagnostic systems that formed the basis for the DSM-III – the diagnostic manual that is the immediate precursor of our current DSM-IV. Rather, it was added to DSM-III largely on the basis of the work of one of the DSM-III task force members who was then studying grief and was carried forward with little modification into DSM-IV.

Second, the other major psychiatric diagnostic system used in the world – the International Classification of Diseases – has never had a grief exclusion criterion for major depression.

Third, a broad range of evidence agreed to by both sides of this debate shows 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 – such as being physical assaulted and raped, being betrayed by a trusted spouse whom you learn has been unfaithful or a beloved child whom you are told is dealing drugs, having your doctor tell you that your breast or prostate biopsy for cancer is positive or the loss of your treasured job. So the DSM-IV position is not logically defensible. 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. This latter approach would represent as major shift, unsupported by a range of scientific evidence, in the nature of our concept of depression as epidemiologic studies show that the majority of individuals develop major depression in the setting of psychosocial adversity.

Fourth, the vast majority of individuals exposed to grief and to these other terrible misfortunes do not develop major depression. That does not mean, and here is the source of much confusion, that they do not grieve. They do. It does not mean that they do not feel terrible pain and loneliness. They do. Depression is a slippery word and we are so used to using it to mean “sad”, “blue”, “upset” or, in this specific case, “grieving.” Major depression – the diagnostic term – is something quite different. Finally, diagnosis in psychiatry as in the rest of medicine provides the possibility but by no means the requirement that treatment be initiated. Watchful waiting is important tool for all skilled clinicians. As a good internist might adopt a watch and wait attitude toward a diagnosable upper respiratory infection assuming that it is unlikely to progress to a pneumonia, so a good psychiatrist, on seeing an individual with major depression after bereavement, would start with a diagnostic evaluation.

If the criteria for major depression are met, then he or she would then have the opportunity to assess whether a conservative watch and wait approach is indicated or whether, because of suicidal ideation, major role impairment or a substantial clinical worsening the benefits of treatment outweigh the limitations. As with the psychiatric response to the other major stressors to which we humans are all too frequently exposed, good clinical care involves first doing no harm, and second intervening only when both our clinical experience and good scientific evidence suggests that treatment is needed.

Validity of the bereavement exclusion to major depression:
does the empirical evidence support the proposal to eliminate the exclusion in DSM-5?
^{by Jerome C. Wakefield and Michael B. First}
World Psychiatry. 2012 11:3-10.

^{The DSM-IV major depression “bereavement exclusion” [BE], which recognizes that depressive symptoms are sometimes normal in recently bereaved individuals, is proposed for elimination in DSM-5. Evidence cited for the BE’s invalidity comes from two 2007 reviews purporting to show that bereavement-related depression is similar to other depression across various validators, and a 2010 review of subsequent research. We examined whether the 2007 and 2010 reviews and subsequent relevant literature support the BE’s invalidity. Findings were: [a] studies included in the 2007 reviews sampled bereavement-related depression groups most of whom were not BE-excluded, making them irrelevant for evaluating BE validity; [b] three subsequent studies cited by the 2010 review as supporting BE elimination did examine BEexcluded cases but were in fact inconclusive; and [c] two more recent articles comparing recurrence of BE-excluded and other major depressive disorder cases both support the BE’s validity. We conclude that the claimed evidence for the BE’s invalidity does not exist. The evidence in fact supports the BE’s validity and its retention in DSM-5 to prevent false positive diagnoses. We suggest some improvements to increase validity and mitigate risk of false negatives.}

The whole point of the DSM-III moving to a diagnostic scheme based on description rather than proposed causality was because we don’t really know what causes many mental illnesses. But there’s no question that if we did, classifying diseases by cause would return with lightning speed. Causality is the bedrock of medical thought. Grief has a known cause. Furthermore, we accept that Grief is normal – an integral component of the human experience reflecting the importance of our attachments to each other. Whether it looks the same as another condition deemed to be pathological or not is immaterial. In medicine, signs and symptoms are generally thought of as pointers to disease causality. The Pneumonias look the same, but we diagnose Pneumococcal Pneumonia or Mycoplasma Pneumonia. Congestive Heart Failure is a symptom complex, but Rheumatic Heart Disease and Coronary Artery Disease are what we list in classifications. The symptom lists of psychiatric diagnosis are a fall-back position – only useful until a cause becomes known. Grief has a cause so it doesn’t belong with depressions where we don’t know the cause. Dr. Kendler’s comment "…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" is correct but his implication is backwards. The sensible conclusion would be to have a category for depression-in-response-to-severe-stressors. We used to have such a thing that needed refining and clarifying, not eliminating. Grief and other precipitated depressions are different from the depressions where there is no precipitant. What’s the difference? The history. History is a time honored diagnostic tool. The notion that we can only use symptom lists for our diagnoses bears no resemblance to the methodology or traditions of medicine.

Dr. Kupfer opens another window into why this DSM-5 Revision Task Force has so many people in a wad. He says, “If someone is suffering from severe depression symptoms one or two months after a loss or a death, and I can’t make a diagnosis of depression — well, that is not being clinically proactive. That person may then not get the treatment they need.” What is he talking about? First, he says "the treatment they need" we can bet he’s talking about antidepressant medication. The diagnosis would be complicated grief, or pathological, grief, or some-other-kind-of grief. He too seems unable to recognize that the symptom lists are a fall-back position, meaningless when the cause is actually known. And, by the way, antidepressants are hardly known for their effectiveness in patients who are clinically depressed in response to real life events. Does he see patients? And if he thinks a given person needs medication for their protracted complicated pathological grief, he could write a prescription. That’s what the rest of us do.

But then there’s this: "Getting the diagnosis increases the likelihood of being treated for what is normal behavior, or close enough. Task force members argue differently: if a person is in distress and seeking help, then treatment ought to be offered — and covered by insurance…" On the face of things, that last part might sound like a benevolent comment, that the DSM-5 Task Force is using these diagnostic categories to make sure that 3rd party payers will reimburse patients for their medical visits and medications when they see the doctor for their protracted grief symptoms. But if you step back a few feet, this is an outrageous motive for a group charged with revising our diagnostic criteria, as outrageous as Dr. Kupfer’s notion that people with pathological grief won’t be treated if we call it what it is. No right-thinking physician runs to the DSM-anything to look up a diagnosis to decide on treatment. Diagnosis doesn’t define treatment, it’s just a piece of the story – sometimes a very small piece.