Last week, an interesting discussion went on in the comments section of a post we published two years ago entitled DSM-V: Getting Closer to Pathologizing Everyone? In order to give this exchange more visibility, we decided to publish it as a separate contribution. First the remarks of Ronald Pies, columnist at Psychiatric Times, and then the response from Alan Horwitz, author of the initial post. We would like to thank both authors for taking the time to share their thoughts on h-madness.
First, the original comment:
It is technically not true that “…anyone who is sad, fails to derive pleasure from usual activities, finds it difficult to concentrate, and has sleep and appetite difficulties for a mere two weeks could be diagnosed with Major Depressive Disorder,” either using DSM-IV or the proposed DSM-5 draft criteria. Those features alone would not meet the full criteria set required for MDD. The person would also need to meet the “C” criterion [in DSM-IV] of “clinically significant distress or impairment in social, occupational or other important areas of functioning.” Moreover, simply being “sad” does not satisfy the criterion of having “depressed mood most of the day, nearly every day…” for 2 weeks.
Most recently bereaved individuals will not meet full DSM criteria for MDD; do not have a “disorder”; and do not need clinical treatment. Furthermore, there are profound phenomenological differences between ordinary grief and MDD that the experienced psychiatrist will recognize. For example, the ability to be consoled, as Kay Jamison has observed, is typically present in ordinary grief, but rarely in MDD.
That said, many of us believe that the 2-week minimum duration is too short, in most cases, to make a confident diagnosis after bereavement or any other major loss, such as divorce. However, this is irrelevant to the validity of the bereavement exclusion, (BE) and focusing on the 2-week minimum both misses the real point of the debate, and obfuscates the many underlying problems with the BE; e.g., there are no controlled, clinical studies (as contrasted with community survey data) of bereaved, MDD patients to support the BE.
The 2-week minimum is a separate problem that must be addressed separately, and in no way justifies continuing the BE. Leaving the BE in the DSM-5 will not fix the general problem of the 2-week interval. Indeed, elimination of the BE from DSM-5 would also rid us of the bogus, 2-month limit on the duration of “normal” bereavement, for which there is no scientific or clinical basis. Ordinary grief related to bereavement is quite distinct from MDD, and may go on for months or even years; it is not a disorder, nor does it require treatment, if the grieving person functions adequately in the social, vocational, and interpersonal spheres.
I hope that readers will take a look at my upcoming blog on the Psychcentral website, entitled, “Grief, Bereavement, and the DSM-5: How the Public is Being Misinformed.” Also, I have developed a preliminary screening instrument, called the PBPI, aimed at helping clinicians distinguish, phenomenologically, between ordinary grief and MDD. It may be found on the Psychiatric Times website, after a free registration step, under the title, “After Bereavement, Is It “Normal Grief” or Major Depression? The PBPI, A Potential Assessment Tool.”
Sincerely,
Ronald Pies MDFor further reading:
Pies R. The two worlds of grief and depression. http://psychcentral.com/blog/archives/2011/02/23/the-two-worlds-of-grief-and-depression/. Accessed January 27, 2012.
Zisook S, Shear K: Grief and bereavement: what psychiatrists need to know. World Psychiatry. 2009;8:67-74.
Zisook S, Reynolds CF 3rd, Pies R, et al. Bereavement, complicated grief, and DSM, part 1: depression. J Clin Psychiatry. 2010;71:955-956.
Lamb K, Pies R, Zisook S. The Bereavement Exclusion for the diagnosis of major depression: to be or not to be? Psychiatry (Edgmont). 2010;7:19-25.
Jamison KR. Nothing Was the Same. New York: Vintage Books; 2011.
Then, the response from Alan Horwitz:
Before the DSM-5 Task Force began its deliberations, the idea that normal grief could be a psychiatric disorder would have seemed preposterous. Freud, for example, following thousands of years of psychiatric thought, noted that:
“Although grief involves grave departures from the normal attitude to life, it never occurs to us to regard it as a morbid condition and hand the mourner over to medical treatment. We rest assured that after a lapse of time it will be overcome, and we look upon any interference with it as inadvisable or even harmful.”
Indeed, the notion that grief is a natural reaction to the death of an intimate is so deeply commonsensical that the general definition of mental disorder in the DSM itself uses it as the sole example of a condition that should not be considered disordered: “(Mental disorder) must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one.”
There are also good empirical reasons for the bereavement exclusion. One of the causes for the original exclusion in the DSM-III was psychiatrist Paula Clayton’s findings that over 40 percent of individuals who had suffered the death of an intimate would meet the MDD criteria in the absence of the bereavement exclusion. Since Clayton used a one-month, rather than the existing two-week, duration that Pies’ suggestion would entail, a majority of the population could likely be diagnosed with major depression using the current diagnostic standards without the exclusion.
A recent study by Ramin Mojtabai uses prospective data from to test the validity of the bereavement exclusion by comparing the prognosis of bereaved and non-bereaved people who have had depressive episodes. Majtabai’s findings show that three years after the initial episode the rate of depression among the bereaved group (8.2%) was comparable to those who were never depressed (7.5%) but significantly lower than the depressed group that was not bereaved (14.7%). Bereaved people are no more likely than people who are not depressed to have subsequent depressive episodes; the prognosis of bereavement is benign compared to other depressed persons; and grieving people, as Freud predicted, are likely to self-heal without treatment. Providing further evidence for the wisdom of maintaining the bereavement exclusion, Majtabai also found that compared to those with other depressive episodes, respondents with bereavement-related episodes were less likely to have impaired role functioning, psychiatric treatment, or comorbid disorders. These findings are likely to understate the differences between the bereaved and others who met MDD criteria because the latter group included people who met these criteria because of other types of losses. Were this group excluded from the MDD group, the differences between the bereaved and non-bereaved group likely would have been even larger.
So, thousands of years of psychiatric history, common sense, and empirical findings all indicate that grief is a natural response to serious loss, not a mental disorder. Why then, does Pies suggest eliminating the current bereavement exclusion? Because the clinical significance criterion of the MDD diagnosis also requires: “clinically significant distress or impairment in social, occupational or other important areas of functioning.” Therefore, according to Pies, only distressed or impaired grieving people will be diagnosed as depressed in the absence of the exclusion. Pies’ rational is odd: obviously grief involves distress. It is part of our nature as humans to feel intense distress after the loss of a loved one. The clinical significance criterion will do nothing to stop the enormous pathologization of grief that abandoning the grief exclusion would entail.
Pies’ eccentric view flies in the face of empirical research, common sense, and thousands of years of psychiatric history, as well as the definition of mental illness in general and depressive disorder in particular, in every previous edition of the DSM. There is no better illustration of the intellectual bankruptcy of current mainstream psychiatric thought than the fact that the DSM-5 is likely to embrace this view. The general public will justifiably be astonished and scornful of the abandonment of the idea that grief is a natural part of life.
h-madness 
The following response to Prof. Horwitz was provided previously:
“Common sense is the name we give to the prejudices we acquire prior to the age of eighteen.” –paraphrase of Albert Einstein’s statement
Rather than belabor the numerous logical, scientific, and clinical problems inherent in Prof. Horwitz’s rejoinder, I would refer readers to the extended debate between Dr. Michael First—who shares Prof. Horwitz’s view on the bereavement exclusion (BE)—and Dr. Sidney Zisook and myself. The debate may be found at:
http://www.medscape.com/viewarticle/740333
Two brief points of clarification:
1. The debate is emphatically not about whether “grief is a natural reaction to the death of an intimate”; nor is it about whether “normal grief” is a psychiatric disorder. I have never met a psychiatrist who would dispute what nearly everyone who has experienced grief knows: uncomplicated grief is an expected and adaptive response to a major loss, and is not a disorder. Grief, to quote Thomas a Kempis, is one of the “proper sorrows of the soul.” The debate concerns the nature and “internal structure” (phenomenology) of grief, vs. the nature and structure of major depressive disorder (MDD); and whether a bereaved, grieving individual who also meets criteria for MDD, anytime within two months after the death, should be “excluded” from the general class of persons with MDD.
My colleagues and I contend there are no clinical studies—that is, of actual depressed patients—that would support such an exclusion rule, and the 40-year old findings of Dr. Clayton, cited by Prof. Horwitz, are methodologically incapable of validating the bereavement exclusion. Moreover, it is simply circular reasoning to argue that recently-bereaved persons who do meet full symptom and duration criteria for MDD are merely showing “normal grief.” That is precisely the question in dispute! In the debate with Dr. First, Dr. Zisook and I show why the data from Clayton et al do not necessarily show that her subjects who met 1970s criteria for major depression were simply experiencing “normal grief;” on the contrary, many may have experienced short-lived (lasting a few months) bouts of bona fide major depression.
The kind of carefully-controlled studies needed to validate the BE have simply never been done. The extracted, survey-based data in Dr. Mojtabai’s study—which did not involve clinical evaluation of actual depressed patients, and cannot control for “recall bias”—do not shed light on the populations seen by psychiatrists and other clinicians. The studies of Karam and others—involving real-world, depressed patients—find no substantial differences in bereavement-related vs. non-bereavement-related depression. [see Karam E: J Affect Disord. 2009 Jan;112(1-3):102-10.] The attempt to argue otherwise is part of a long-discredited notion that we can distinguish “depression with cause” from “depression without cause”, or show that “reactive” vs. “endogenous” depressive episodes differ markedly in course, outcome, or response to treatment. [see Kessing L: Acta Psychiatr Scand Suppl. 2007;(433):85-9; Pies R: J Affect Disord. 2009 Jul;116(1-2):1-3. Epub 2008 Dec 4.]. Of course, in carrying out psychotherapy with depressed patients, “cause” and context (including loss) do become very important issues.
2. The debate is not about whether there are flaws in the current or proposed DSM-5 criteria for a major depressive episode—almost certainly, there are. Specifically, the “two week” criterion is not the issue in the debate about the BE. The 2 week duration issue is misleading on several counts:
First, it is extremely rare for a bereaved individual to consult a clinician within 2 weeks of a death of a loved one, unless something has gone very seriously wrong; e.g., the person is suicidal or has developed a psychotic depression. (In those cases, the person often comes in via the emergency room, or is brought in by a worried family member). The BE becomes moot in such cases, since it is not applied when the patient is showing suicidality, psychosis, and other “conditional” features considered markers of serious pathology.
Second, leaving the BE in DSM-5 will not solve the problem with the 2-week criterion, which would apply after any major loss, such as divorce, job loss, etc. My colleagues and I have advocated a longer assessment period (3-4 weeks, in most cases) before applying the MDD diagnosis [see Lamb et al, Psychiatry (Edgmont). 2010 Jul;7(7):19-25.] and I personally favor “tighter” entry criteria for MDD; e.g., expanding the number of required symptoms from 5 to 6 or 7. These issues, however, need to be considered separately from the BE.
Finally, given that suicide rates do not appear to differ between so-called “reactive” and other types of depression [Kessing L, Psychopathology. 2004 May-Jun;37(3):124-30. Epub 2004 May 18], my colleagues and I believe that there is considerable risk in excluding bereaved persons who meet full MDD criteria from the general class of MDD sufferers. When a depressed patient seeks professional help after bereavement, diagnosing MDD does not compel the clinician to begin antidepressant treatment. Rather, the diagnosis of MDD allows and encourages further assessment, and provides the patient with a professional support system, in case the depressive symptoms worsen. If the patient improves spontaneously over the subsequent weeks, no treatment may be necessary. Once again: we do not want to “medicalize” grief; but neither do we want to “normalize” clinically serious depression.
Ronald Pies MD
Note: I am aware of the highly-publicized, recent paper by Wakefield & First in the February 2012 issue of World Psychiatry. There, Wakefield and First argue that existing studies have not “invalidated” the bereavement exclusion, based on several putative methodological flaws in these studies. (“We conclude that the claimed evidence for the BE’s invalidity does not exist.”) I believe that this argument turns logic and scientific method on its head. The burden is for those who want to retain the BE to show that it was valid in the first place; if it was not, then it either needs to be eliminated or validated through appropriately-designed studies. It is emphatically not the burden of critics of the BE to “invalidate” it!
i am undecided as to whether a major depression is able to cope equally well with bereavement, and whether such an individual can distinguish between normal sadness and the ongoing depressive dysfunctionality such as social withdrawal. And then, is it not a time for dispensing temporarily with medication, when grief is stronger than the overall low affect ? This will allow for an unimpeded experience of grief. Yet, on the other hand, the experience is so negative, that medication could be offered. I would not call this over-medication, although you may disagree.