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.