Thursday, January 26, 2012

Bereavement is Sad, but it's not a Depressive Illness

The status of bereavement in the next edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders ("DSM") is in the news again.

DSM IV, first published in 1994, defines "major depression" by a constellation of symptoms. Depressed mood and/or loss of pleasure capacity must be present, along with symptoms like sleep disturbance, fatigue, restless agitation or a feeling of being slowed down, loss of appetite and diminished ability to concentrate. The symptoms must represent a change from prior status and be present for at least two weeks. All of these symptoms may be present in normal bereavement.

Crucial for the current controversy, DSM IV included what has been called a "bereavement exclusion." The diagnosis of depressive illness is not made if:
The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
The DSM V committee that is working on criteria for major depression is proposing to drop the bereavement exclusion, largely based on research taken to imply that the exclusion isn't empirically supported. In a rather technical article, Jerome Wakefield and Michael First from NYU and Columbia, pick apart that research and argue that the exclusion should be retained.

This isn't a matter of arcane definitions and paperwork. Dropping the exclusion will lead to an epidemic of overdiagnosis of depressive illness when what's really happening is painful grief. Overdiagnosis will have harmful consequences, including:
  • Medication will often be prescribed. While anti-depressants are relatively well tolerated, all medications can cause harm through side effects.
  • Grief typically resolves over time. When this happens, at least some of those taking medication will attribute their improvement to the drug. This can alter self image - "I fell apart when X died - thank God the medicine and the doctor got me out of it."
  • Many will stay on the drug and attribute their ongoing wellbeing to its continued use, at the cost of recognizing their own capacity to recover from a painful loss and the potential side effects from long term drug use.
  • Even if no harm accrues from diagnosis and medication use, unnecessary interventions will add unnecessary costs for individuals and the wider community.
  • And, for all those suffering from normal, though painful, grief, medicalization of the condition may distract from normal healing processes - tears, preoccupation with the loss, rituals, and more.
Dr. Kenneth Kendler, a member of the DSM V work group, argues that these fears aren't warranted:

...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...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.  
"Watchful waiting" is indeed an important tool for skilled clinicians. If clinicians, the public, and pharmaceutical companies, all conducted themselves in accord with Dr. Kendler's wise precepts, the bereavement exclusion wouldn't matter.

But, alas, this prudent approach to clinical practice is in too short supply in American medicine. We're an activist society. Watchful waiting in the face of a serious diagnosis is almost un-American. That's why "watchful waiting," the wisest approach for many men with early prostate cancer, has had to be rebranded as "active surveillance."

If the bereavement exclusion is dropped, it's only a matter of time until media will be flooded by pharmaceutical advertisements targeted at individuals who have suffered loss and their well intentioned families.

Since the American Psychiatric Association agrees with Dr. Kendler that "good clinical care involves first doing no harm," DSM V should retain the bereavement exclusion!


Mark said...

Hi, Jim:
As always, such a thoughtful post.

I keep reminding myself that Im a long-time employee of APA and therefore certainly biased (and maybe more than a little brainwashed.) It seems to me that the people working on DSM 5 are getting hit with a tsunami of criticism (several recent NYT pieces about the bereavement exclusion and redefinition of autism). I cant help thinking that there is in the popular imagination this idea that a bunch of guys are sitting around dreaming up new diagnoses. But as that biased, possibly brainwashed long time employee, and one who has written about these issues in PN, I do know that there is an extensive deliberative process behind all of these proposed changes. And there is one other interesting point the workgroup has made (as has Dr. Kendler) which I think is at least arguable: virtually all depression occurs in the context of some psychosocial adversity. So why exclude bereavement and not (say) depression related to job loss?

Well, an interesting point anyway. You know how much I admire your thinking. And I continue to recommend your blog.
Mark M.

Jim Sabin said...

Hi Mark -

Thank you for your comment, and for your kind words!

I hope I didn't convey a picture of the DSM V work group as a cabal of cigar smoking men scheming behind closed doors. I found Dr. Kendler's comments thoughtful, cogent, and clinically wise. If all clinicians practiced as he recommends, we'd have no problems. But in a country of 300 million, where most people in a state of grief will be seen by non-psychiatrists, I fear that the combination of (a) patient and clinician wanting "something to be done" and (b) a panoply of drugs that will be marketed to assist with grief, will (c) lead to the bad consequences I envisioned.

Your point, and Dr. Kendler's, about other stressors triggering "depression-like" states, is quite correct. But bereavement is a universal experience and has been a central preoccupation for societies since ancient times. As such I think it warrants special attention.

The "tsunami of criticism" comes from the political and economic importance of the DSM. The autism community fears that the proposed altered definition will reduce the number of diagnoses and reduce access to insurance-covered interventions. With the bereavement exclusion the fear is the opposite - that there will be a flood of newly diagnosed cases of major depression under the new criteria.

As cogent as Dr. Kendler's argument is, in my view the risks coming from the proposed change outweigh the benefits of the change.



Benny said...

Psychiatry and Japan’s “National Disease”

Jim Sabin said...

Hi Benny

Thank you for the link. It's a fascinating story Junko Kitanaka tells. I'm going to try to get her book.

Readers - the linked post, which I encourage you to go to - describes the way what we in the U.S. would probably think of as depression has been thought of differently in Japan. At the extreme, the author describes Japanese reluctance to entertain the hypothesis that suicide may reflect the illness of depression rather than a wise personal choice.

From a U.S. perspective, the U.S. is at risk for overmedicalization, as by labelling grief as depressive illness. From this same perspective, Japan would seem to be at risk of undermedicalization, as in construing suicide in situations other than terminal illness as wise personal choice rather than as the illness of depression.

Medical anthropology, the field of the author, is endlessly fascinating!