COMMENTARY

Depression or Bereavement? Defining the Distinction

Michael B. First, MD; Ronald W. Pies, MD; Sidney Zisook, MD

Disclosures

April 08, 2011

In This Article

Potential Costs of Eliminating the Bereavement Exclusion

8. "On the other hand, fixing the problem by eliminating the bereavement 'exclusion' altogether...carries with it a number of potential significant costs...[including] unnecessary treatment, stigmatization by family, friends and self, and other negative discriminatory effects, such as being unable to obtain disability insurance or life insurance...because of having a diagnosis of [MDD] in one's medical record."

  • We acknowledge that these adverse outcomes are theoretical risks; however, we do not believe the best way to address them is by retaining an unsupported diagnostic directive. The issues of "stigma," discrimination, denial of insurance coverage, etc are best addressed through policies of strict confidentiality, public education, healthcare reform, and legislative remedies. Our diagnostic system should not be used as an instrument to head off anticipated political, social, or economic injustices. The issue of unnecessary treatment is a valid concern, in so far as inappropriate prescription of antidepressants could have negative (side) effects for some grieving patients. On the other hand, it is hard for us to see how involving a depressed, bereaved patient in competently conducted supportive psychotherapy would place the patient at significant risk, even if a provisional diagnosis of MDE turns out to be mistaken. Moreover, some open data suggest that antidepressant treatment may actually improve ratings of grief in parallel to those of depression.[17] Furthermore, a recent study by Corruble and colleagues[18] found no difference in antidepressant response rates in bereaved subjects seeking treatment for depression, but excluded from the diagnosis of MDE, vs MDE controls. That said, we acknowledge the pressing need to provide more intensive consultation and education to primary care physicians who might lean toward premature prescription of antidepressants. We also need to improve access to competent psychotherapy.[19]

9. "... in our current cultural climate...it is not hard to imagine how [a] clinician might feel pressured to write down a diagnosis of MDE on the chart (with all of the future potential for negative consequences) in order to justify the writing of a prescription for a psychotropic medication."

  • In theory, perhaps so, but we can also imagine primary care physicians already feeling countervailing pressure not to diagnose MDD, for precisely the reasons Michael First suggests above, eg, a wish not to "stigmatize" the patient, concerns regarding discriminatory insurance practices, etc. Again, we believe these issues must be addressed by means external to our diagnostic system.

10. "...the cost of eliminating the bereavement exclusion is to encourage the reification of the major depressive syndrome which...does not define a real disease but merely... a particular set of symptoms [that] have clustered together during the same 2-week period. Its removal is basically sending the message that clinical judgment is not required when making a psychiatric diagnosis... [just checking off symptoms]..."

  • We share Dr. First's concerns that the current construct of MDD has intrinsic problems, eg, marked heterogeneity, a lack of reliable biomarkers, and excessively brief minimal duration criteria. But these are matters to be dealt with by refining our MDD criteria -- for example, by making them more stringent or by including more melancholic features in the criteria set -- not by retaining an unsupported "exclusion" criterion. As for the "message" that symptom checklists are all that are needed for psychiatric diagnosis, one easily could make the same argument for the entire DSM system! We have suggested that the phenomenology of grief and depression (the inner world and "felt experience" of the patient) ought to be described in the DSM-V text, so that clinicians can better understand the very real experiential differences between "normal" grief and major depression.[7,20] This discrimination certainly does require clinical judgment.

11. "Finally, by eliminating an exclusion criterion explicitly designed to avoid obvious false positives (eg, normal grief), the DSM-V Mood Disorder Work Group's proposal provides fodder to a skeptical public who suspects that a main goal of the DSM-V is to increase business for mental health professionals."

  • Here, too, we do not believe the remedy to such public cynicism involves manipulating our diagnostic classification; to do so for fear of public criticism is to collude in the stigmatization of our profession. Instead, we need to redouble our public education and outreach efforts.

12. "...maintaining this worthwhile [exclusion] criterion in the DSM-V criteria for MDE would result in the continued perpetuation of the logical inconsistency of handling the loss of a loved one differently than other stressors..."

  • Indeed, we agree. In addition, preserving the bereavement exclusion will also perpetuate the serious disjunction between the DSM and the International Classification of Diseases (ICD) classification, since the ICD does not recognize a bereavement exclusion.

13. "[Nonetheless]...any attempt to 'fix' this conceptual problem by either eliminating the criterion or expanding it to include other stressors will end up making the situation much worse..."

  • This, of course, is speculation. We know of no evidence that the ICD system, which lacks a bereavement exclusion, has created any problems of overdiagnosis, for example. Moreover, most reliable data suggest that only a relatively small percentage of patients (< 9%) presenting with MDD symptoms would be affected by elimination of the bereavement exclusion[12] Corruble data.

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