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After Removal from DSM-5, Why Clinicians Should Remember the Bereavement Exclusion

After Removal from DSM-5, Why Clinicians Should Remember the Bereavement Exclusion

 

February 18, 2013

Jerome C. Wakefield, PhD, DSW

 

School of Social Work, Department of Psychiatry; New York University, NY

 

First published in Psychiatry Weekly, Volume 8, Issue 4, February 18, 2013

 


 

Introduction

After undergoing its first major overhaul in nearly 20 years, the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is slated for a May 2013 release.

Of the many changes in DSM-5, one of the most controversial is the removal of the DSM-IV’s “bereavement exclusion” (BE) to major depressive disorder (MDD), which allows clinicians to defer making a clinical diagnosis of MDD when certain depressive symptoms occur within the context of recent bereavement and do not last more than 2 months. Under this exception, such an episode is classified as a “V-code,” signifying the absence of mental illness.

Complicated vs. Uncomplicated Bereavement

“Some depressive symptoms routinely occur during normal grief,” says Dr. Jerome Wakefield. “However, depressive illness can be triggered by grief. The underlying issue is how to decide whether depression symptoms during bereavement represent normal grieving or a depressive disorder superimposed on grieving. It’s estimated that one-third to one-half of all people who experience the death of a loved one display enough depression symptoms during the early months of grieving to qualify for a clinical diagnosis of MDD under current criteria. Yet, the condition is generally self-correcting. The BE was designed to solve that symptom overlap problem and avoid misdiagnosing normal grief as depressive disorder. With the BE eliminated, each clinician will now have to make this judgment independently, or else any grieving person who has depressive symptoms just 2 weeks after a loss will qualify for an MDD diagnosis.”

Most people emerge gradually and predictably from the grieving process along with its inherent depressive feelings. The BE offered diagnostic guidelines for distinguishing normal from disordered depressive syndromes during grief. It specified that normal (or “uncomplicated”) bereavement-related depression is characterized mainly by general distress symptoms, such as feeling sad, crying, decreased appetite, insomnia, difficulty concentrating, and decreased interest in regular activities. A small proportion of the bereaved, however, experience “complicated bereavement-related depression,” which goes beyond general distress symptoms to include one or more of the following: suicidal ideation, psychotic thinking, psychomotor retardation, sense of worthlessness, severe functional impairment, or prolonged duration (>2 months). The BE specifies that even during bereavement such complicated episodes should be diagnosed as MDD.

"With the BE eliminated, clinicians will now have to judge
independently whether any grieving person who has
depressive symptoms 2 weeks after a loss will qualify for an MDD diagnosis."

Dr. Wakefield’s research indicates that the BE’s rules have much to recommend them. He finds that uncomplicated bereavement-related—or other stressor-related—depressive syndromes generally have markedly lower levels of pathological features than complicated or endogenous/psychotic depressions.1,2 Also, uncomplicated depressions do not recur like other depressions; persons who experience a single episode of uncomplicated bereavement-related depression are no more likely to have a recurring depressive episode by 3-year follow-up than persons with no lifetime history of depression.3,4

“In light of solid evidence that uncomplicated bereavement-related depression is similar to uncomplicated reactions to other stressors,5,6 I and other researchers suggested expanding the BE in DSM-5 to apply to uncomplicated stressor-related depressions generally,” says Dr. Wakefield. “However, extension of the BE was rejected out of hand.7 Instead, based on the similarity evidence, the DSM-5 Mood Disorders Work Group argued that bereavement is not special, so the BE should be eliminated. This latter argument ultimately won the day.”

Although the BE was eliminated, the Mood Disorders Work Group effected a sort of compromise, according to Dr. Wakefield. They included a footnote acknowledging an overlap in symptoms between normal stress-related depression and clinical depression, and advised clinicians to use their judgment in these situations.

“The footnote has problems, but I was delighted by some aspects of it,” says Dr. Wakefield. “First, the footnote gets rid of the 2-month threshold for when grief-related depressive feelings become pathological; there was no basis for that threshold to begin with.8 Secondly, it extends the BE to other stressors, such as financial ruin, natural disaster, illness, etc, which are also associated with normal depressive feelings. The problem, however, is that the footnote contains no diagnostic criteria, just some vague general comments, which makes this subgroup virtually impossible to study. These normal reactions to stressors can now fall under the MDD diagnosis in a drug trial, for example, and since they remit relatively quickly on their own, you wouldn’t be giving the experimental drug a fair test against placebo. So for research, this is problematic. For psychiatric epidemiology, this is potentially a disaster.”

Clinical Implications

One important concern that was used to argue for removal of the BE is that suicidal MDD cases might be missed. Dr. Wakefield’s ongoing research has found, however, that persons falling under the BE’s rules virtually never attempt suicide,1,2 and unpublished data indicate that on follow-up they have no more likelihood of a suicide attempt than a random member of the population. “That is something that should reassure clinicians,” he says.

Nor is there good evidence that antidepressants, particularly SSRIs, are needed or effective for uncomplicated bereavement-related depression.

“Giving medication to those with uncomplicated depressive reactions to bereavement or other stressors should be thought through very carefully,” says Dr. Wakefield. “There is evidence that this subgroup doesn’t need medication, and some hypothesize that psychotropics administered early could interfere with the natural grief process. The clinical implications of recent research are straightforward: aside from as-needed treatments for anxiety, insomnia, etc, this is a subgroup that can be reassured and treated much less aggressively.”9



Disclosure: Dr. Wakefield reports no affiliations with, or financial interests in, any organization that may pose a conflict of interest.


This interview was conducted on January 29, 2013 by Lonnie Stoltzfoos

References:

1. Wakefield JC, Schmitz MF. Normal vs. disordered bereavement-related depression: are the differences real or tautological? Acta Psychiatr Scand 2013;127:159-168.

2. Wakefield JC, Schmitz MF. Can the DSM's major depression bereavement exclusion be validly extended to other stressors?: Evidence from the NCS. Acta Psychiatr Scand. 2013. [Epub ahead of print]

3. Mojtabai R. Bereavement-related depressive episodes: characteristics, 3-year course, and implications for the DSM-5. Arch Gen Psychiatry. 2011;68:920-928.

4. Wakefield JC, Schmitz MF. Recurrence of depression after bereavement-related depression: Evidence for the validity of the DSM-IV bereavement exclusion from the Epidemiologic Catchment Area Study. J Nerv Ment Dis. 2012;200:480-485.

5. Wakefield JC, Schmitz MF, First MB, Horwitz AV. Should the bereavement exclusion for major depression be extended to other losses? Evidence from the National Comorbidity Survey. Arch Gen Psychiatry. 2007;64:433-440.

6. Kendler KS, Myers J, Zisook S. Does bereavement-related major depression differ from major depression associated with other stressful life events? Am J Psychiatry. 2008;165:1449-1455.

7. Wakefield JC. Should uncomplicated bereavement-related depression be reclassified as a disorder in DSM-5?: Response to Kenneth S. Kendler’s statement defending the proposal to eliminate the bereavement exclusion. J Nerv Ment Dis. 2011;199:203-208.

8. Wakefield JC, Schmitz MF, Baer JC. Relation between duration and severity in bereavement-related depression. Acta Psych Scand. 2011;124:487-494.9.

9. Horwitz AV, Wakefield JC. The loss of sadness: How psychiatry transformed normal sorrow into depressive disorder. New York:Oxford University Press;2007.