Lancet Weighs in on DSM-5 Bereavement Exclusion

Megan Brooks

February 16, 2012

February 16, 2012 — An editorial that appears in this week’s Lancet expresses concerns about the proposed elimination of the bereavement exclusion to major depression in the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) from the American Psychiatric Association (APA).

The bereavement exclusion for major depression in the fourth edition of the DSM recognizes that depressive symptoms are sometimes normal in recently bereaved individuals. However, bereavement exclusion is slated for elimination in DSM-5. This has become one of the more contentious issues regarding DSM-5, which is scheduled to be published in May 2013.

As reported last week by Medscape Medical News, an article published in World Psychiatry this month makes the case for keeping the bereavement exclusion to major depression. The coauthors of the article conclude that the "claimed evidence" for its invalidity does not exist. The author of a linked commentary in the journal agreed.

Depression or Normal Grief?

The Lancet editorial notes that taking out the bereavement exclusion "means that feelings of deep sadness, loss, sleeplessness, crying, inability to concentrate, tiredness, and no appetite, which continue for more than 2 weeks after the death of a loved one, could be diagnosed as depression, rather than as a normal grief reaction."

In an accompanying essay, Arthur Kleinman, MD, professor of medical anthropology from Harvard University in Boston, shares his experience with grief after his wife died in March 2011.

He notes that it took 6 months before his intense feelings of sadness and yearning became "less acute," and nearly 1 year later, he feels "sadness at times" and harbors "the sense that a part of me is gone." He asks: "Is there anything wrong (or pathological) with that?"

Medicalizing grief, so that treatment is legitimized routinely with antidepressants, for example, is not only dangerously simplistic, but also flawed. The evidence base for treating recently bereaved people with standard antidepressant regimens is absent.

The editorial cautions that "[m]edicalizing grief, so that treatment is legitimised routinely with antidepressants, for example, is not only dangerously simplistic, but also flawed. The evidence base for treating recently bereaved people with standard antidepressant regimens is absent."

In an interview with Medscape Medical News, APA President John M. Oldham, MD, cautioned: "The last thing I as president of the APA — or the APA — wants is to inappropriately specify that somebody would have an illness when that's not the case. That is not at all something that we would support or be interested in, so the notion that we are sort of 'medicalizing' the world or have some motivation to want to increase the numbers [of depressed people] out there is just not correct."

Dr. John Oldham

Targeted Intervention

The Lancet editorial notes that although bereavement is associated with adverse health outcomes, both physical and mental, interventions are "best targeted at those at highest risk of developing a disorder or those who develop complicated grief or depression, rather than for all."

When we say that we are recommending removing this exclusion of grief from the diagnosis of depression, people have misinterpreted this to mean that therefore everyone who is grieving after the loss of a spouse will be diagnosed as depressed. That is not at all the case.

Dr. Oldham agrees. "When we say that we are recommending removing this exclusion of grief from the diagnosis of depression, people have misinterpreted this to mean that therefore everyone who is grieving after the loss of a spouse will be diagnosed as depressed. That is not at all the case," he said.

Dr. Oldham also made the point that in general, people who are under a lot of stress or are going through a rough period are not necessarily going to be diagnosed with depression.

"Even if you meet the criteria for depression, it doesn't mean that you're going to have treatment slapped on you. It just means that maybe you'd have a conversation about it with your doctor and perhaps agree to a watchful waiting period and be alert to how things go and maybe check in a little more frequently. Nothing is automatic; there are lots of options."

The bottom line, Dr. Oldham said, is "we want people to get treatment who need it."

Thoughtful Discussion

"Occasionally," the Lancet editorial acknowledges, "prolonged grief disorder or depression develops, which may need treatment, but most people who experience the death of someone they love do not need treatment by a psychiatrist or indeed by any doctor. For those who are grieving, doctors would do better to offer time, compassion, remembrance, and empathy, than pills."

Dr. Oldham emphasized that the proposed elimination of the bereavement exclusion was not a snap decision. "There was a lot of very thoughtful discussion about it. Nobody saw it as just clear as it could be. It was not an immediately agreed upon consensus" — and rightly so, he said. "This is something that is sensitive and needs to be thought about carefully, and we recognize that," said Dr. Oldham.

He also noted that the bereavement exclusion as written in the DSM-IV is "very limited; it only applies to a death of a spouse or a loved one. Why is that different from a very strong reaction after you have had your entire home and possessions wiped out by a tsunami, or earthquake, or tornado; or what if you are in financial trouble, or laid off from work out of the blue? In any of these situations, the exclusion doesn't apply."

"What we know," Dr. Oldham said, "is that any major stress can activate significant depression in people who are at risk for it. It doesn't make sense to differentiate the loss of a loved one as understandable grief from equally severe stress and sadness after other kinds of loss."

Lancet. 2012;379:589,608-609.

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