Tuesday, June 12, 2012

Bereavement, Depression and DSM-V

In January I criticized the American Psychiatric Association (APA) for planning to drop the "bereavement exclusion" from the definition of major depressive disorder in the forthcoming new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Under the exclusion, the diagnosis of depression 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.
In a recent issue of the New England Journal of Medicine, Richard Friedman, a distinguished psychiatrist at Cornell who writes excellent New York Times columns for general readers, adds to the voices criticizing the APA for medicalizing normal grief (see here). Here's the essence of Friedman's argument:
In removing the so-called bereavement exclusion, the DSM-5 would encourage clinicians to diagnose major depression in persons with normal bereavement after only 2 weeks of mild depressive symptoms. Unfortunately, the effect of this proposed change would be to medicalize normal grief and erroneously label healthy people with a psychiatric diagnosis. And it will no doubt be a boon to the pharmaceutical industry, because it will encourage unnecessary treatment with antidepressants and antipsychotics, both of which are increasingly used to treat depression and anxiety...The medical profession should normalize, not medicalize, grief.
Despite criticism the DSM-V working group has not changed its plan to eliminate the bereavement exclusion, but it has added a footnote that at least acknowledges the challenge of distinguishing normal grief from the illness of depression:
The normal and expected response to an event involving significant loss (e.g, bereavement, financial ruin, natural disaster), including feelings of intense sadness, rumination about the loss, insomnia, poor appetite and weight loss, may resemble a depressive episode. The presence of symptoms such as feelings of worthlessness, suicidal ideas (as distinct from wanting to join a deceased loved one), psychomotor retardation, and severe impairment of overall function suggest the presence of a Major Depressive Episode in addition to the normal response to a significant loss.
I don't know if Dr. Friedman would be mollified by this footnote, but I'm not. For those who want to delve more deeply into the research, the working group presents its rationale here.

To my eye, clinical and epidemiological research relevant to distinguishing the illness of depression from the painful but not unhealthy state of grieving doesn't settle the controversy. The DSM-V working group has chosen to drop the bereavement exclusion out of fear that it might lead to misdiagnosis of some depressive episodes as normal grief. I, along with Dr. Friedman and other critics, see the potential for medicalizing normal grief as a significantly greater danger.

Years ago, when I was teaching a group of primary care physicians about use of antidepressant medication, one of the PCPs commented in the form of a two-line poem:
I know what to do when they're dying,
But not what to do when they're crying.
Between the degree to which harried physicians have become less skilled at dealing with existential concerns like grief and the seductive pharmaceutical marketing that will emerge with the death of the bereavement exclusion, before too long we'll be seeing patients experiencing normal grief being flogged with unwarranted diagnoses and unneeded medication.

Grief typically lifts on its own without medical intervention. Some of these patients and their physicians will conclude that they have been "cured" by the unneeded medication and will remain on it, exposing them to pharmacological side effects. In addition, some will experience an altered self image - "I'm a 'weak' person who got sick when X died and needed medicine to get over it" - rather than "I miss X terribly and experienced severe grief after the death."

The DSM-V working group is factually correct in its belief that loss can trigger the illness of depression and that it's important for clinicians not to miss the diagnosis when this happens. But dropping the bereavement exclusion won't eliminate this risk, and eliminating the exclusion will add to a destructive cultural trend of over-medicalization and excessive use of pharmaceuticals.


tyler said...

This is very interesting, and it is easy to see how someone might easily believe that there grief could be cause for medication, even if the state is completely normal in bereavement and will be eliminated naturally over time.

Jim Sabin said...

Hi Tyler -

You understand the problem I see in what the DSM-V working group has concluded. I know from my own clinical experience that intense grief can look like a depressive illness. One problem in our current environment is that we expect physicians to "do something," and often a prescription is the "something" that gets done in circumstances where a return visit or prompt telephonic follow up would be a better course of action.



Carey said...

Great piece, and a bit upsetting how grief and bereavement are becoming medicalized. And to the point you made, medicalizing them shapes a particular identity of being "weak," rather than being purely human and missing someone like crazy. Having worked in end of life care for the past 8 years, I am also taken aback with the lack of services/resources that help take care of the providers and healers who work around terminal illness for example, and have their own grief and loss to work through, yet still provide care for our loved ones. A different and unique understanding of how grief and bereavement work in unusual (not routine) ways, will certainly shed like on policy and education initiatives in the clinic and even in organizations. Thanks.

Jim Sabin said...

Hi Carey -

Thank you for your thoughtful comments.

Support for providers who work with end of life care is VERY important. There's a wonderful program dedicated to that area - the Kenneth Schwartz Center for Compassionate Care. Their signature program is "Schwartz Center Rounds," in which folks like yourself work together with a facilitator to address the experiences you have identified. I've participated in the rounds and can testify first hand that (a) the issue you write about is widely shared and (b) empathic discussion with colleagues can provide crucial insight and support.



Thomas said...

I'm not a psychologist/iatrist, but I disagree with the lumping of "the feelings involved with bereavement" with "major depression".

I would offer - though have no data to support such a move - that these "-opathies" have entirely different origins, courses, treatment options.

While they appear to be similar (the symptom complexes), it is not at all clear that the underlying neurobiology is the same.

Certainly with the high incidence of depressive disease, bereavement could complicate one of those syndromes.

Most of us, however, will learn to live with loss, and should do so without the interference of pharmacology. I think we will one day recognize that our pills are part of the problem.

Jim Sabin said...

Hi Thomas -

Thank you for your very thoughtful comment. I agree that bereavement and depressive illness can look alike. I see the greater danger as over-medicalizing normal (though painful) grief than failing to diagnose depressive illness. There's no doubt that mistakes can be made in both directions, but treating a grieving person as a sick person for whom medication is likely to be prescribed and a diagnosis will be made feels like a sacrilege, not just a diagnostic error.

I love the way you put forth a strongly held opinion and, at the same time, acknowledge that you don't have data for it. When we don't own up to not having data we're being arrogant. But when we don't express a strongly held opinion we're being too timid!



Nikki Elyce said...

Though I am a little late coming in to the conversation, I just wanted to thank you for sharing your well informed opinion. I too am quite concerned about the upcoming DSM, (for other reasons as well) and this is one of the most thoughtful pieces I have come across regarding the blurring of the line between clinical depression and normal grief. When you are dealing with a manual that decides how people are medically treated, but is based on subjective, non-medical external criteria, it is imperative that the guidelines be as clear, meaningful and informative as possible.

This brings me to a larger concern - As a society in general, we seem to have less and less tolerance for what should be normal ranges of emotions. Grief is seen as something to avoid, or as Carey said, or somehow shameful. Being nervous walking into a party means you have social anxiety disorder. There are many other examples, especially if you start looking a childhood diagnoses.

Changes to the DSM such as this not only effect clinical practice, but also set a dangerous precedent for defining what is "normal".

Jim Sabin said...

Hi Nikki -

Thank you for the comment and the kind words.

I share your concern that psychiatry and our wider society are "medicalizing" aspects of experience that would better be thought of as part of "normal life." There are many drivers of this trend. It creates mega-markets for pharmaceuticals and expands referral opportunities for mental health clinicians.

Time is also a factor. It's more "efficient" to jump to a diagnosis and write a prescription. I had a very educational experience as a resident in psychiatry in the "walk in" clinic where we spent half time for half of the year that made me appreciate how being hurried can distort our judgment. A woman came in with her husband and siblings requesting shock treatment, which she had received several times before. She was in a state of depression and anxiety. There was no one else for me to see that afternoon, so I simply talked with her - probably for an hour or more. As we chatted, she began to identify stressors. Her body relaxed and her emotional symptoms chilled out. I brought the family in and we talked more. The "patient" got more relaxed. After a couple of hours the group left, with some practical ideas about how to address the problematic situation.

In my practice I found it useful to employ terms that connoted eccentricity rather than illness - terms like "odd duck." It's important to diagnose illness when it's really there, but it's also important not to convince people that they're ill when a better understanding is that they're suffering from the slings and arrows of life itself!