“Have the psychiatrists gone mad? — those who weren’t crazy to begin with! They want to turn grief into a disease!”
This might well be the attitude of many in the general public, having read the misleading news coverage of a debate over the DSM-5 — the still-preliminary diagnostic classification of mental disorders, often referred to as “psychiatry’s Bible.” Now, I am no fan of the DSM model of diagnosis — in fact, if the DSM is the “bible,” I’m something of a heretic. In my view, the DSM’s superficial symptom checklists are great for research purposes, but not very useful for most clinicians or patients.
Nevertheless, I don’t like seeing the work of my DSM-5 colleagues misrepresented. So when I see bogus headlines like, “Grief Could Join List of Disorders” in the usually circumspect New York Times, I cringe.
Before discussing the arcane debate over the “bereavement exclusion,” it’s important to understand what most psychiatrists really believe about grief, bereavement, and depression.
No psychiatrist I know believes that grief is a disorder, disease, or abnormal condition that requires treatment. And nobody connected with the DSM-5 believes that either! Grief is ordinarily a useful, adaptive emotion that follows a major loss, such as the death of a loved one (bereavement) or the breakup of an intimate relationship.
Indeed, the 15th century monk, Thomas a Kempis, recognized that there are “proper sorrows of the soul,” and that “…we often engage in empty laughter when we should rightly weep.” Psychologist Kay R. Jamison — writing in the wake of her husband’s death — described grief as “…a generative and human thing… it acts to preserve the self.” (from Nothing Was the Same). Grief might be considered the price we pay for forming deep and intimate attachments.
It is true that following the death of a loved one, many bereaved individuals will show some signs or symptoms that overlap with those of clinical depression — what psychiatrists call major depressive disorder (MDD). In addition to feelings of intense sadness or anguish, the recently bereaved person may eat and sleep poorly for several weeks; have difficulty concentrating; and withdraw from most social activities.
But it’s important to note that most recently bereaved individuals will not meet the full DSM-IV criteria for a major depressive episode. Most are able to carry on their everyday functions and activities at a higher level than individuals with MDD. The current debate over the bereavement exclusion (BE) arises when someone who has lost a loved one within the past two months consults a doctor, and is noted to meet the full symptom and duration criteria for a major depressive disorder. To understand the implications of this, let’s consider two hypothetical scenarios:
“Mrs. Brown” is a 28-year-old mother of two, whose husband was killed in Afghanistan three weeks ago. She sees her family doctor and says, “I’m still in shock. Of course, I knew Bob was always at risk, but I still can’t believe it. I barely functioned at all for the first week after he died, then I dragged myself back to work at the office — but it’s really hard to concentrate on anything. God, I miss Bob so much! I’m taking care of the kids pretty well, but I am in so much pain, I cry almost every day. I keep seeing Bob’s face, his smile. Sometimes, I have wonderful memories of all the things we did together. I’m having a terrible time falling asleep, though, and I’m wondering if maybe I could get something for that? My appetite isn’t very good, either, and I don’t make any effort to go out and meet people. But I do appreciate it when friends call or drop by, though. I guess I’ll eventually get back to being my old self, and I do want to go on with life, but it’s really hard! What should I do, Doctor?”
Most good doctors will recognize Mrs. Brown as having the expected and “normal” grief that follows bereavement—and nothing we anticipate from the DSM-5 will change that. While some physicians might prescribe medication to help Mrs. Brown sleep, very few knowledgeable physicians would prescribe an antidepressant, assuming this is the totality of Mrs. Brown’s complaints. Based just on the information above, there is good reason to reassure Mrs. Brown that—with love, support, and enough time — she will get through this tragedy without professional help. Those diligent doctors who actually bother to pick up the DSM-IV (or the expected DSM-5) will discover that Mrs. Brown falls short of the criteria for a major depressive episode. Indeed, there is nothing anticipated from DSM-5 that would deny Mrs. Brown a diagnosis of “appropriate grief due to bereavement” or that would “label” her as having a mental disorder. Dropping the BE from DSM-5 would make no difference in a case like this, since the BE is an option only when the bereaved patient fully meets symptom and duration criteria for a major depressive episode within two months of a love one’s death.
Now let’s consider “Mr. Smith.” He is a 72-year-old retired businessman whose wife died of cancer three weeks ago. He visits his family doctor and says, “I feel down in the dumps and weepy every day, Doc—really lousy! I don’t get any pleasure out of anything anymore, even stuff I used to love, like watching football on TV. I wake up at 4 in the morning almost every day, and I have zero energy. I can’t keep my mind on anything. I barely eat, and I’ve lost 10 pounds since Mary passed away. I hate being around other people. And sometimes I feel like I didn’t really do enough for Mary when she was sick. God, how I miss her! I can still cook for myself, pay the bills, and so on, Doc, but I’m just going through the motions. I don’t enjoy life at all anymore.”
Though it’s still early after his wife’s death, wise and experienced clinicians will be very concerned about Mr. Smith. He easily meets DSM-IV and DSM-5 (draft) symptom and duration criteria for MDD. (A previous bout of MDD in his history would strengthen the likelihood, as would several other clinical findings I have omitted). And yet, under the current DSM-IV “rules,” Mr. Smith probably would not be diagnosed with a major depressive illness. He would simply be called “bereaved.” Why? Because he is still within the 2-month period that allows for use of the bereavement exclusion; and because — based on the facts presented — Mr. Smith doesn’t have the features that would “override” use of the BE, such as severe functional impairment, suicidal ideation, psychosis, morbid preoccupation with worthlessness, or extreme guilt. Ironically, if Mr. Smith’s wife had left him for another man, he would meet MDD criteria, using current DSM rules — go figure!
So, if the bereavement exclusion is retained in DSM-5, patients like Mr. Smith would likely be told, “You are just having a normal reaction to the death of your wife.” Probably, no treatment would be offered, and none covered by insurance. My colleagues and I believe this is a serious mistake, with potentially devastating consequences — including the risk of suicide.
Contrary to much fear-mongering in the press, our position does not imply that Mr. Smith should be started on an antidepressant. It means that the doctor should seriously consider a diagnosis of MDD; meet again with Mr. Smith in another 1-2 weeks; and consider the advisability of supportive psychotherapy. Medication could be an option if Mr. Smith significantly worsens or becomes suicidal. Combined “talk therapy” and medication would also be an option if he is much worse in a week or two. And, yes — some patients with Mr. Smith’s clinical picture may spontaneously improve within a few more weeks. That, of course, does not mean Mr. Smith’s grief will be at an end.
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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