The Case for Retaining Bereavement Exclusion in DSM-5

Megan Brooks

February 06, 2012

February 6, 2012 — The "bereavement exclusion" (BE) to major depression contained in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) is valid and should remain in the DSM-5, according to authors of a special article published in the February issue of World Psychiatry.

Through the notion of BE for major depression, DSM-IV recognizes that depressive symptoms are sometimes normal in recently bereaved individuals. However, BE for major depression is slated for elimination in DSM-5. Those in favor of this action contend that the empirical evidence demonstrates that BE is invalid. This has become one of the more contentious issues regarding DSM-5, which is slated for publication in May 2013.

In the article, Jerome C. Wakefield, PhD, DSW, of New York University, and Michael B. First, MD, of Columbia University, both in New York City, state that the "claimed evidence for BE's invalidity does not exist."

"In the argument to expand the category of major depression by eliminating the [BE], the evidence that has been cited has not been relevant to the issue," Dr. Wakefield told Medscape Medical News.

Medscape Medical News contacted the American Psychiatric Association (APA) for comment and was referred to APA member M. Katherine Shear, MD, professor of psychiatry at Columbia University in New York City. Dr. Shear is a DSM-5 work group advisor.

The issue of diagnosing depression in the context of bereavement is "a very important one, and the controversy over it is getting a little bit polarized. What's being discussed at the moment is, get rid of the BE or don't. My personal opinion is that that's the wrong discussion. We shouldn't get completely rid of it because it is a differential diagnosis and it needs to be mentioned in the DSM."

Major Implications

Dr. Wakefield noted that eliminating the BE will have major consequences. It means, for example, that "just a few weeks after the loss of a loved one, if one feels the general distress symptoms that also occur during depression, one will be diagnosed as having major depression, even if the depression is transient and even if it contains none of the more severe symptoms [such as] suicidal ideation, slowed thought or movement, or preoccupation with one's worthlessness."

The main argument for eliminating the BE is that bereavement-related depressions are just like other depressions, Dr. Wakefield and Dr. First write. This stems largely from 2 reviews published in 2007 (Zisook et al, Psychol Med 2007;37:779-794, and Zisook et al, World Psychiatry, 2007;6:102-107) and a subsequent review published in 2010 (Lamb et al, Psychiatry, 2010;7:19-25).

Drs. Wakefield and First examined these 3 reviews, as well as other relevant research, and concluded that "the evidence in fact supports BE's validity and its retention in DSM-5 to prevent false-positive diagnoses."

The evidence to support the elimination of the BE is "flawed," said Dr. Wakefield. "The reviews and studies that are cited either study bereavement-related depression in general and do not examine the specific milder depressions distinguished as normal by the exclusion, or they have other methodological problems that render them irrelevant to the evaluation of the exclusion's validity," he said.

In addition, Dr. Wakefield noted that 2 more recent studies comparing recurrence of BE-excluded depression and other cases of major depression both support the validity of the BE. These 2 new studies are "methodologically rigorous…and both find that excluded depressions have recurrence rates that are not above general population levels, whereas other depressions have quite high recurrence rates."

"The evidence suggests that the excluded episodes are best considered a normal variation in bereavement and not a mental disorder," he added.

Reflection Advisable

In an accompanying editorial, Mario Maj, MD, PhD, of the Department of Psychiatry, University of Naples, Italy, and chairperson of the World Health Organization Working Group on the Classification of Mood and Anxiety Disorders, concludes that the removal of the BE from the diagnosis of major depressive episode can only be justified by "strong and unequivocal new research evidence. Wakefield and First's review...suggests that such a solid and consistent new evidence is not available."

"Further reflection," Dr. Maj writes, "seems therefore warranted before proceeding with the deletion of the bereavement exclusion."

If the BE is eliminated, Dr. Wakefield worries that "millions of people with transient normal depressive symptoms during grief will be incorrectly diagnosed as having a mental disorder."

His other concerns include "increased prescriptions for medication yielding side effects in many who do not need medication; increased stigma for those who grieve more intensely; and increased social pressure to quickly get over the loss of a loved one; and less tolerance of intense negative human emotion, even for legitimate mourning of losses."

Dr. Shear believes the problem with the BE is that it is "very specific and over-specified." The BE states that if the depressive episode lasts longer than 2 months after the loss or includes at least 1 feature uncharacteristic of normal grief, including marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation, then the episode should be diagnosed as major depressive disorder.

However, "there are people who 3 or 4 months out [from the loss] who are still grieving intensely who we would not want to diagnose with depression, and there are people at 4 weeks who we would diagnose with depression, " Dr. Shear explained.

Natural Process

In their article, Drs. Wakefield and First suggest some changes to the BE that "could improve its validity and limit its misuse." One is the use of a "provisional" qualifier for cases of excluded bereavement in which depressive symptoms have not resolved by 8 weeks.

Another improvement in BE criteria that would protect against missing genuine cases would be to incorporate the requirement that past history of major depression disqualifies a bereavement-related depression for exclusion.

Drs. Wakefield and First also suggest getting rid of the "potentially confusing double-negative wording."

Dr. Wakefield said response to the article has been "generally positive."

"From the general public, most agree and are worried about interfering with the natural grieving process," he said. The feedback from mental health professionals has also been "mostly positive," he added.

"However, the group of psychiatrists who have been behind the push to eliminate the exclusion, including those on the DSM-5 Mood Disorders Work Group, have thus far ignored the review and the new evidence entirely."

Dr. Shear believes that clinicians need to be alerted to the fact that normal grief should not be mistaken for depression and also that depression can sometimes occur in the context of bereavement. "The DSM-IV tries to do this but fails because of over-specification of the time frame and the criteria," she said.

Potent Triggers

"Clinicians are not interested in diagnosing someone who is grieving normally as having major depression, and it's typically not difficult to tell them apart," Dr. Shear said.

Grief is a response to bereavement in which the sadness is always accompanied by a deep sense of yearning and longing for the person who died. The sadness is totally focused on that person, she explained.

"However, any stressor can trigger an episode of major depression, and we know that interpersonal conflict or loss are especially potent triggers of depression in people who are vulnerable to depression."

The authors of the current article, she added, "neglect to mention the downside of missing a depressive episode during bereavement."

World Psychiatry. 2012;11:1-10. Article, Editorial

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