Patients Are More Complex Than the DSM’s Category System
But there is a deeper issue here: namely, the inadequacy of the entire DSM “one from column A, one from column B” approach. That may make for good reliability if you are doing research, but it doesn’t penetrate very deeply into the subjective experience—the “inner world”—of the bereaved person.
It turns out that this is quite different for the person with ordinary bereavement, compared with that of the patient with major depression. Like Mrs. Brown, the bereaved person often experiences 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. The bereaved person 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 an emotional connection with friends and family, and often can be consoled by them. The person suffering a major depressive disorder is usually too self-focused and emotionally “cut off” to enjoy the company of others. Indeed, Kay Jamison has pointed out that “The capacity to be consoled is a consequential distinction between grief and depression.” My colleagues and I are now developing a screening questionnaire, based on these distinctions. (This instrument, called the Post-Bereavement Phenomenology Inventory, has not yet been validated. A preliminary version of the PBPI appears here)
The bereavement exclusion was developed with good intentions, following seminal studies in the 1970s by Dr. Paula Clayton showing that many bereaved patients will have some depressive symptoms for weeks or months after the loss. But there is no conclusive evidence, based on controlled studies, that bereaved persons meeting modern-day MDD criteria have markedly different outcomes from patients with “standard” (non-bereaved) MDD.
In the past two decades, most of the clinical outcome data show that if you meet full criteria for MDD, it doesn’t make much difference whether the depression did or did not follow a recent loss, or came “out of the blue:” your symptoms, level of impairment, ability to function, and response to treatment will be roughly comparable. Furthermore, the current DSM features designed to distinguish bereavement from MDD — suicidal feelings, intense guilt, etc. — appear to have little predictive value, and may be present in roughly equal numbers in both bereaved and non-bereaved MDD patients.
The Bereavement Exclusion Should be Removed
In my view, it was an error to have created the bereavement exclusion in the first place — a bit like implanting a defective valve in a patient with heart disease. (Note that the “ICD” system — the International Classification of Diseases, used throughout the world — does not use a formal bereavement exclusion rule). Those who argue for maintaining the bereavement exclusion claim that this is a “conservative” position that will prevent over-diagnosis and overmedication.
But my colleague, Dr. Sidney Zisook, and I believe that there is no sound, scientific basis for the bereavement exclusion; that it interferes with the recognition and treatment of major depression, a potentially lethal illness; and that the potential problem of overmedication is one we should deal with through proper medical education, especially of primary care doctors — not through preemptive jiggering with our diagnostic criteria. In short, I believe that the “defective valve” needs to be removed.
Some critics who want to retain the bereavement exclusion focus on the DSM-5 draft’s two-week minimum duration criterion for a MDE. They argue that, in the case of the bereaved patient, the DSM-5 framers “want to put a two-week time limit” on grief. This is really a distortion, as we saw in the case of Mrs. Brown. To be sure: the very brief, two-week period is usually not enough time to permit a confident diagnosis of major depression, in my view — after bereavement or any other major loss, such as a recent divorce.
But the two-week issue is distinct from that of eliminating the bereavement exclusion, and only muddies the waters of the debate. Keeping the bereavement exclusion in DSM-5 won’t fix the general problem of the two-week criterion — that needs to be taken up by DSM-5 as a separate issue.
At the same time, I strongly believe the DSM-5 should get rid of the arbitrary and misleading two-month guideline for normal bereavement. Grief, and its attendant anguish, sometimes lasts months or even years. By itself, there is nothing “disordered” in prolonged grief, if the person is largely able to function and flourish in life.
Ideally, acute grief gradually becomes integrated into the larger fabric of the person’s life — so-called “integrated grief.” Most grieving individuals will do fine with “tincture of time” and the love and support of friends and family. Some who develop the syndrome of “complicated grief,” however, may need professional help. And when recent bereavement is accompanied by the features of a major depressive disorder, professional attention is required to determine if treatment is needed. Sometimes, very mild depressive episodes resolve without formal treatment. If not, mild-to-moderate depression usually responds to psychotherapy. More severe cases may require medication or “combined” treatment (medication and talk therapy).
We should never assume that bereavement “immunizes” the individual against a bout of major depression. We don’t want to “medicalize” ordinary grief. But neither should we “normalize” serious depression following a major loss.
Thanks to Dr. Sidney Zisook for comments on an early draft of this commentary, and to Dr. Katherine Shear for her seminal work on complicated grief.
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