“Have the psychiatrists gone mad? — those who weren’t crazy to begin with! They want to turn grief into a disease!”
This might well be the attitude of many in the general public, having read the misleading news coverage of a debate over the DSM-5 — the still-preliminary diagnostic classification of mental disorders, often referred to as “psychiatry’s Bible.” Now, I am no fan of the DSM model of diagnosis — in fact, if the DSM is the “bible,” I’m something of a heretic. In my view, the DSM’s superficial symptom checklists are great for research purposes, but not very useful for most clinicians or patients.
Nevertheless, I don’t like seeing the work of my DSM-5 colleagues misrepresented. So when I see bogus headlines like, “Grief Could Join List of Disorders” in the usually circumspect New York Times, I cringe.
Before discussing the arcane debate over the “bereavement exclusion,” it’s important to understand what most psychiatrists really believe about grief, bereavement, and depression.
No psychiatrist I know believes that grief is a disorder, disease, or abnormal condition that requires treatment. And nobody connected with the DSM-5 believes that either! Grief is ordinarily a useful, adaptive emotion that follows a major loss, such as the death of a loved one (bereavement) or the breakup of an intimate relationship.
Indeed, the 15th century monk, Thomas a Kempis, recognized that there are “proper sorrows of the soul,” and that “…we often engage in empty laughter when we should rightly weep.” Psychologist Kay R. Jamison — writing in the wake of her husband’s death — described grief as “…a generative and human thing… it acts to preserve the self.” (from Nothing Was the Same). Grief might be considered the price we pay for forming deep and intimate attachments.
It is true that following the death of a loved one, many bereaved individuals will show some signs or symptoms that overlap with those of clinical depression — what psychiatrists call major depressive disorder (MDD). In addition to feelings of intense sadness or anguish, the recently bereaved person may eat and sleep poorly for several weeks; have difficulty concentrating; and withdraw from most social activities.
But it’s important to note that most recently bereaved individuals will not meet the full DSM-IV criteria for a major depressive episode. Most are able to carry on their everyday functions and activities at a higher level than individuals with MDD. The current debate over the bereavement exclusion (BE) arises when someone who has lost a loved one within the past two months consults a doctor, and is noted to meet the full symptom and duration criteria for a major depressive disorder. To understand the implications of this, let’s consider two hypothetical scenarios:
“Mrs. Brown” is a 28-year-old mother of two, whose husband was killed in Afghanistan three weeks ago. She sees her family doctor and says, “I’m still in shock. Of course, I knew Bob was always at risk, but I still can’t believe it. I barely functioned at all for the first week after he died, then I dragged myself back to work at the office — but it’s really hard to concentrate on anything. God, I miss Bob so much! I’m taking care of the kids pretty well, but I am in so much pain, I cry almost every day. I keep seeing Bob’s face, his smile. Sometimes, I have wonderful memories of all the things we did together. I’m having a terrible time falling asleep, though, and I’m wondering if maybe I could get something for that? My appetite isn’t very good, either, and I don’t make any effort to go out and meet people. But I do appreciate it when friends call or drop by, though. I guess I’ll eventually get back to being my old self, and I do want to go on with life, but it’s really hard! What should I do, Doctor?”
Most good doctors will recognize Mrs. Brown as having the expected and “normal” grief that follows bereavement — and nothing we anticipate from the DSM-5 will change that. While some physicians might prescribe medication to help Mrs. Brown sleep, very few knowledgeable physicians would prescribe an antidepressant, assuming this is the totality of Mrs. Brown’s complaints. Based just on the information above, there is good reason to reassure Mrs. Brown that — with love, support, and enough time — she will get through this tragedy without professional help. Those diligent doctors who actually bother to pick up the DSM-IV (or the expected DSM-5) will discover that Mrs. Brown falls short of the criteria for a major depressive episode. Indeed, there is nothing anticipated from DSM-5 that would deny Mrs. Brown a diagnosis of “appropriate grief due to bereavement” or that would “label” her as having a mental disorder. Dropping the BE from DSM-5 would make no difference in a case like this, since the BE is an option only when the bereaved patient fully meets symptom and duration criteria for a major depressive episode within two months of a love one’s death.
Now let’s consider “Mr. Smith.” He is a 72-year-old retired businessman whose wife died of cancer three weeks ago. He visits his family doctor and says, “I feel down in the dumps and weepy every day, Doc — really lousy! I don’t get any pleasure out of anything anymore, even stuff I used to love, like watching football on TV. I wake up at 4 in the morning almost every day, and I have zero energy. I can’t keep my mind on anything. I barely eat, and I’ve lost 10 pounds since Mary passed away. I hate being around other people. And sometimes I feel like I didn’t really do enough for Mary when she was sick. God, how I miss her! I can still cook for myself, pay the bills, and so on, Doc, but I’m just going through the motions. I don’t enjoy life at all anymore.”
Though it’s still early after his wife’s death, wise and experienced clinicians will be very concerned about Mr. Smith. He easily meets DSM-IV and DSM-5 (draft) symptom and duration criteria for MDD. (A previous bout of MDD in his history would strengthen the likelihood, as would several other clinical findings I have omitted). And yet, under the current DSM-IV “rules,” Mr. Smith probably would not be diagnosed with a major depressive illness. He would simply be called “bereaved.” Why? Because he is still within the 2-month period that allows for use of the bereavement exclusion; and because — based on the facts presented — Mr. Smith doesn’t have the features that would “override” use of the BE, such as severe functional impairment, suicidal ideation, psychosis, morbid preoccupation with worthlessness, or extreme guilt. Ironically, if Mr. Smith’s wife had left him for another man, he would meet MDD criteria, using current DSM rules — go figure!
So, if the bereavement exclusion is retained in DSM-5, patients like Mr. Smith would likely be told, “You are just having a normal reaction to the death of your wife.” Probably, no treatment would be offered, and none covered by insurance. My colleagues and I believe this is a serious mistake, with potentially devastating consequences — including the risk of suicide.
Contrary to much fear-mongering in the press, our position does not imply that Mr. Smith should be started on an antidepressant. It means that the doctor should seriously consider a diagnosis of MDD; meet again with Mr. Smith in another 1-2 weeks; and consider the advisability of supportive psychotherapy. Medication could be an option if Mr. Smith significantly worsens or becomes suicidal. Combined “talk therapy” and medication would also be an option if he is much worse in a week or two. And, yes — some patients with Mr. Smith’s clinical picture may spontaneously improve within a few more weeks. That, of course, does not mean Mr. Smith’s grief will be at an end.
37 comments
Many thanks to Dr. Grohol and Psychcentral for hosting my essay! Just a note to readers: as per my standing policy regarding online etiquette, I reply directly only to questions or comments that are fully-signed, and that advance the discussion in a collegial manner.
I look forward to a good exchange on on this much-misunderstood and controversial topic!
Best regards,
Ronald Pies MD
“Contrary to much fear-mongering in the press, our position does not imply that Mr. Smith should be started on an antidepressant. It means that the doctor should seriously consider a diagnosis of MDD; meet again with Mr. Smith in another 1-2 weeks; and consider the advisability of supportive psychotherapy.”
When you write these posts, do you really think about all the implications to what is at hand here, or, are you just spouting off what is the theoretical world of psychiatry in academia and forget that 70% or more of antidepressant meds come from non psychiatrists? I really take issue with your inconsistencies in your continual posts on this topic. This is about lumping grief into a depression code in the end. And I have met plenty of people, both patients in the office and people in my personal travels, who resent being told to basically take a pill and move on. This is what the DSM5 is selling.
It is nothing less than incredible in a disappointing way how people who are the alleged Key Opinion Leaders in our field either don’t get it, have sold out, or live unintentionally by the adage “the road to hell is paved with good intentions”.
Sometimes you just can’t be the mensch all the time!
Dr. Pies always uses the qualifier *knowledgeable* as in “*knowledgeable* physicians” would not leap to prescribe an antidepressant or he’s never heard a *knowledgeable* psychiatrist espouse the “chemical imbalance” theory.
This is habitual tautology. Anyone who does such foolish things cannot be *knowledgeable*.
Therefore, as long as patients visit an elite of *knowledgeable* doctors, they are safe from irresponsible prescribing and pie-in-the-sky theories.
No problem! It’s simply up to the patient to frequent the right doctors, the ones who know the DSM-5 isn’t saying what it appears to be saying.
Dr. Pies,
Thank you for sharing your perspective on this important issue. However, a central component of your argument doesn’t make sense to me. You state that “if the bereavement exclusion is retained in DSM-5, patients like Mr. Smith would likely be told, ‘You are just having a normal reaction to the death of your wife.’ Probably, no treatment would be offered, and none covered by insurance.”
By your logic, this is what should be happening now because the bereavement exclusion currently remains in place. However, is there any evidence that this is the case? Certainly no competent professional I know has ever used the bereavement exclusion to turn away a bereaved client who was feeling depressed. Sure, professionals may not be diagnosing bereaved clients with major depressive disorder (MDD), but that doesn’t mean they aren’t treating said clients or that insurance companies aren’t reimbursing them. Instead, professionals are simply assigning grieving clients equally reasonable but less stigmatizing diagnoses than MDD, which permit provision of exactly the same services. If there is any evidence that insurance companies demand a diagnosis of MDD before covering services for the bereaved, I’d be curious to see it.
My point is that therapists are already able to do precisely what you say is only possible if the bereavement exclusion is eliminated: they monitor clients, offer supportive psychotherapy and–if improvement doesn’t occur—consider a medication referral. The bereavement exclusion doesn’t stop people from receiving appropriate treatment. It may discourage us from pathologizing bereavement, but it doesn’t prevent us from helping those who experience it.
Jonathan D. Raskin, Ph.D.
Member, Society for Humanistic Psychology’s Open Letter Committee
Your article misses the point. Any professional (or human being) should be willing to help someone who is having a hard time. But we don’t have to diagnose everyone have a hard time with a “Mental Disorder” (a label that will follow them the rest of their lives) in order to be compassionate and to make sure our patients get whatever assistance is appropriate. The problem with DSM-5 as currently proposed is that it may result in the labeling of individuals with a mental disorder when, in reality, they are simply going through the normal and emotionally painful difficulties of life. So if you are a psychiatrist, psychologist, counselor, pastor, or human being — please help anyone who shows up need your assistance. But don’t conclude you have to diagnose them with a “mental disorder” before offering your help. True, the insurance company may not pay you but that’s okay. You will survive financially, I suspect. Regardless, we professionals shouldn’t diagnose a person as “mentally ill” just so we can get paid.
I have dealt with depression for half of my life (since age 14 — I’m 29 now), and only once have I been referred to a counselor or psychiatrist by a doctor. Usually it’s just meds and follow-ups on those meds. I’ve even changed doctors before and there was only minimal questioning of my symptoms before writing an Rx and sending me on my way. I have been without insurance more often than not, which also poses issues as to whether counseling would even be affordable for me. I believe that before the issue of a BE can be settled, more physicians need to have a better understanding of depression in general, and should be willing to take the time to refer a psychiatrist or counselor rather than just taking out the Rx pad.
It seems that the grief process and span of time after a loss has been lost in this study. These two case studies involve people who are just “weeks” into the grieving process. I think diagnosing someone with a major depressive order and medicating them, would be counter productive so soon after their loss and mask their grief and skip some vital phases of grief. The grieving process is a necessity for survivors. Perhaps time off from work, counseling, group therapy and giving them perimission to embrace their sadness would help them more. If a patient is still struggling 9mos., or more, later and is still lacking some normalcy to their routine, then doctors should consider more extensive treatment.
Nice pick up on the time line to those two cases. I’m genuinely curious to see if colleagues would offer opinion on diagnosing MDD with a person “depressed” who has no prior history of mood disorder episodes now following an external
event like a death or other loss like unemployment or financial calamity.
My diagnosis is MDD or bipolar II, depending on the doctor (a different issue). Over several years’ experimentation, neither antidepressants nor mood stabilizers have proved effective. A variety of therapies: psychotherapy, diet, exercise, peer support, education, stress management, regular routine keep me on a relatively even keel.
So when my mother died recently, disrupting all of the above, I was concerned about my health and monitored it carefully. I am blogging a series on the Bereavement Exclusion. The phenomenological portion is at http://prozacmonologues.blogspot.com/2012/02/griefdepression-iii-telling-difference.html — how I could tell the difference between my natural, healthy grieving process and the relapse into a diagnosable depressive episode that followed.
Three points: I can tell, anybody who takes time to listen can tell, Dr. Pies is urging you to take time to tell the difference between grief and depression. But these are NOT mutually exclusive conditions. People who have depression deserve treatment, regardless of whether they have the additional misfortune of a recent bereavement.
Second: These accusations that Dr. Pies is selling antidepressants have no basis in what he has written. Therapy comes in many forms. It is a pity that so many psychiatrists and family practitioners both have become little more than psychopharmacologists, but that is a separate issue. Dr. Pies is not one of them. Meds don’t work for me. When I recognized that I was relapsing, well within the two month BE, my CBT therapist got me back on track in my recovery.
Third: Psychiatrists need to look to themselves on this stigma issue. Out in the real world, unemployment, getting fired because you can’t get yourself out of bed, and don’t have a medical excuse, now there is stigma. Major Depression is a bummer; it is not a source of shame. Cancer used to be stigma. Thank God oncologists didn’t withhold treatment in order to avoid it.
Many thanks to all who have taken the time to comment! I have read your thoughtful posts with great interest, and I’ll respond with some substantive comments shortly. –Best regards, Ron Pies MD
Before responding to some specific criticisms and comments, I’d like to put the issue of the
bereavement exclusion in a larger perspective. As my colleague, Dr. Allen Frances has observed,
the issue of the BE seems to be the “by far the biggest object of public concern” among the
various DSM-5 proposals. [Psychiatric Times, March 1, 2012]. Why is this so? I believe part of
the controversy stems from inaccurate portrayals in the media, such as the one I cited in the
NY Times. But I also believe that the BE has become a kind of lightening rod for many simmering
grievances among some in the general public–and among a sub-group of American psychiatrists.
The BE seems to be a kind of “proxy” for what some see as psychiatry’s excessive use of
medication; its over-involvement with “Big Pharma”; its focus on “medicalizing normality”, etc.
There is certainly room to debate each of these concerns, but they are not fundamentally related
to the issue of the BE, and only muddy the conceptual waters.The real debate is simply about whether one ought to “exclude” a diagnosis of major depressive disorder (MDD) when a bereaved person meets full symptom and duration criteria for MDD, any time within 2 months of the death. My colleagues and I would answer “No, you should not exclude MDD simply
because the person is “grieving” over a death within the past 2 weeks or 2 months.”
As Willa Goodfellow astutely observes, grief and MDD “…are NOT mutually exclusive conditions.
People who have depression deserve treatment, regardless of whether they have the additional
misfortune of a recent bereavement.”
Nor does “treatment” imply medication, notwithstanding the increasing use of antidepressant
medication in recent years, primarily by non-psychiatric (primary care) physicians, as noted
by Dr. Hassman. As a psychiatric educator who has spoken to PCPs on the issue of antidepressants,
I do not accept the cynical proposition that primary care doctors are hopeless, incompetent drones
who will unthinkingly hand out antidepressants to all bereaved persons!
Yes, there is probably unnecessary (and perhaps unhelpful) prescribing of these medications in some primary care settings (1)–but this is properly the object of intensified medical education and consultation–not of jiggering our diagnostic criteria to head off anticipated bad practices.Moreover, there are numerous studies showing that in some settings, antidepressants are either under-utilized or inadequately-dosed. Thus, Mojtabai and Olfson (2008) found that racial/ethnic minorities continued to receive antidepressant treatment at a lower rate compared to non-Hispanic whites, raising concerns about undertreatment in some minority groups (1). Similarlly, Gonzalez et al found that Mexican American and African American individuals meeting 12-month major depression criteria consistently had lower odds for any depression therapy,including medication (2).
In short, there is evidence of both over- and under-use of antidepressant medication.
Now to the concerns raised by Dr. Elkins and Dr. Raskin. Dr. Elkins believes I have missed
“the point” and goes on to make what I take to be two distinct points: (1) “We don’t have to
diagnose everyone hav[ing] a hard time with a “Mental Disorder†(a label that will follow them the rest of their lives) in order to be compassionate and to make sure our patients get whatever assistance is appropriate…”; and (2) “The problem with DSM-5 as currently proposed [dropping the BE] is that it may result in the labeling of individuals with a mental
disorder when, in reality, they are simply going through the normal and emotionally painful difficulties of life. On the first point, I am of course in agreement, and nobody is suggesting that “everyone” having a “hard time” be given a psychiatric diagnosis! If the client/patient indeed receives “compassionate” and “appropriate” assistance, then we have fulfilled our primary ethical obligation. Unfortunately, if the clinician fails to recognize the presence of MDD, and mistakenly
concludes that the patient is experiencing “normal” grief, it is unlikely that the patient will
receive appropriate care; indeed, there is no professional care required for most cases of
uncomplicated grief, whereas most cases of MDD will require some type of treatment.
As for Dr. Elkins’second point, I’m afraid I find it essentially a form of begging the question; that is,
asserting as a fact precisely what is in dispute. When a recently bereaved person presents the
panoply of major depression symptoms,it is precisely the question of “normality” that is being
debated. So Dr. Elkins’ claim that the patient is “in reality” experiencing a normal emotional
reaction merely uses the proposition to be proved as one of the premises in his argument; i.e., this is simply circular reasoning.
I also do not accept the premise that a diagnostic “label” is something we must diligently avoid, either in psychiatry or in general medicine. As Ms. Goodfellow notes, there is nothing shameful in
experiencing a bout of depression. To be sure: this diagnosis must be kept in the strictest
confidence, but, in my view, we merely feed popular prejudice by avoiding accurate diagnosis merely for the sake of not “labeling” someone.The more we treat psychiatric diagnoses as “scarlet letters”, the more we perpetuate the pejorative stereotypes that surround psychiatric patients. Finally, the issue of insurance is, in my view, one of making sure that the patient does not need to pay “out of pocket”–it is not simply a selfish need on the clinician’s part to
“get paid.”
Dr. Raskin raises several concerns and questions. First, he wonders if there is any “evidence” that
depressed, bereaved individuals are being turned away, under the present DSM-IV use of the
bereavement exclusion. Notwithstanding Dr. Raskin’s personal experience, I do not believe
we have any accurate data to answer that question. There is, however, good evidence that in primary care settings, only about 50% of depressed patients are recognized as such.(3) I doubt that the BE per se accounts for such a high rate of missed depression, since only a small fraction of MDD patients present during the first few weeks after bereavement. Rather,
I suspect it is due largely to the average PCP’s lack of time and sophistication in recognizing MDD. (And
psychiatrists have not done a great job in “reaching
out” and assisting PCPs, either).
That said, I do think that many primary care MDs (and, alas, some psychiatrists) fall into
what I call “the fallacy of misplaced empathy.” That is, “If I can understand how the patient
came to be depressed, then it’s not a clinical depression. I can understand how anybody who
loses a loved one would be depressed; therefore, that patient is reacting normally and doesn’t
need treatment.” This, in my view, is a completely fallacious, and even dangerous, line of
reasoning. (This same fallacy is the foundation for the widely-read book, “The Loss of Sadness”,
by Horwitz and Wakefield). Curiously, no doctor ever denies a patient coming out of surgery a pain
medication, on the specious rationale that “Hey, anybody coming out of surgery would be in pain!
That’s just normal!”
Dr. Raskin also wonders if patients treated for simple bereavement are denied insurance coverage. To the best of my knowledge, under most insurance plans, the so-called “V” codes in the DSM-IV, including “Bereavement”, are not “billable” (4). That said, there may be cases in which the diagnosis, “Adjustment Disorder with Depressed Mood” could be used to characterize some mildly-depressed, recently-bereaved patients, and–if accurately applied–I
have no problem with that. Adjustment disorders are billable under most insurance plans, to my
knowledge. In short, while there is little if any “evidence” that use of the current BE leads
to denied services, I am not convinced that depressed patients or clients simply deemed “bereaved”
will be able to receive appropriate services covered by their insurance policies. Of course,
that does not stop the therapist from providing treatment at a greatly reduced fee–which, in
fact, is what I often did for indigent patients, when my practice was active.
Finally, a comment on the two case vignettes in my essay. They were not designed to reveal the
full complexity of the grieving process, which (as I indicated) may go on for months or even
years, without necessarily being “pathological.” The cases were merely designed to illustrate
that dropping the BE from DSM-5 does not inherently lead to labeling all recetnly-bereaved patients
as clinically depressed, even within the first 2-3 weeks after bereavement. In actual clinical
practice, however, it is very, very rare that a bereaved person seeks psychiatric help during
the first 2-3 weeks after the death, unless something has gone terribly wrong; e.g., the person has developed suicidal feelings, psychosis, or severe incapacity–and in such cases, the issue
of the BE becomes moot, since it would be “overridden” using present DSM rules. Incidentally,
there is no credible evidence that medication interferes with or “masks” the grieving process
in bereaved patients who also meet criteria for MDD; on the contrary, there is evidence from small, open studies that antidepressant treatment in those cases leads to a parallel decline in both grief intensity and depressive symptoms.(5). But once again, and I hope for the final time: I do not advocate antidepressant treatment for the ordinary grief of bereavement!
Thanks again to all who have commented, and I’m sorry for this lengthy response and poor formatting!
Best regards,
Ron Pies MD
1. Mojtabai R, Olfson M. National trends in psychotherapy by office-based psychiatrists.
Arch Gen Psychiatry. 2008;65:962-970
2. González HM, Vega WA, Williams DR, Tarraf W, West BT, Neighbors HW. Depression care in the
United States: too little for too few. Arch Gen Psychiatry. 2010 Jan;67(1):37-46.
3. Egede LE: Failure to Recognize Depression in Primary Care: Issues and Challenges.
J Gen Intern Med. 2007 May; 22(5): 701–703.
4. Psychotherapy and insurance: the double bind
by Dolores Puterbaugh http://findarticles.com/p/articles/mi_m1272/is_2708_132/ai_n6019807/
5. Zisook S, Shuchter SR, Pedrelli P, Sable J, Deaciuc SC.Bupropion sustained release for
bereavement: results of an open trial. J Clin Psychiatry. 2001 Apr;62(4):227-30.
Thank you for making the point in your reply that antidepressants are often underprescribed! The opinion that they’re vastly overprescribed is so often stated that people seem to accept that assumption as fact.
Even so, Dr. Pies understates the problem, implying that medicalization of relatively normal conditions and overprescription of antidepressants are only occasional events — a position belied by recent CDC statistics: Antidepressant Use in Persons Aged 12 and Over: United States, 2005–2008 http://www.cdc.gov/nchs/data/databriefs/db76.htm
Only by resolutely ignoring evidence of prescribing patterns and pervasive failure of GPs (or psychiatrists) to monitor patients on psychiatric medication could a defender of the DSM-5 contend that such mispractice is hardly a danger and critics are crying wolf.
I stand by my position as a practicing psychiatrist both in community mental health and private practice positions. I respect Dr Pies’ opinion, I just counter with this for readers to consider: much of what is proposed is by academic and non practicing psychiatrists who don’t work the front lines of daily mental health care.
Plus, I never said or implied “drones” as PCPs, but if that is your interpretation of my first comment in this thread, Dr Pies, let it be said that much of what PCPs go by in their mental health education is via psychiatry KOLs, who in my opinion do not have a good track record via what has been revealed about the role of pharmaceutical coercion.
And to infer at least that is not a possible concern with the development of DSM 5 is baffling, considering what I have read in Psychiatric Times these past several months.
I encourage readers to explore all the points of view in this debate.
Thank you for your thoughtful reply, Dr. Pies. I agree that we do not have data to answer whether or not people are being denied treatment for major depression based on the bereavement exclusion. Yet in your original blog post you said DSM-5 needed to remove the bereavement exclusion or else patients would be denied treatment for depression–even though there is no evidence to support that this is occurring now with the bereavement exclusion still in place. Therefore, it is your very claim that is the one lacking research support. DSM-5’s authors say they want decisions about changes to diagnostic criteria to be rooted in research. If they remove the bereavement exclusion based on your rationale, their decision will occur despite the lack of evidence to support said rationale.
Thanks for your comments, Dr. Raskin. I think we may be differing mainly on a few semantic issues, more than on substantive ones. To be accurate: I did not actually write, in my article, that “patients would be denied treatment for depression” if the BE is retained in DSM-5.
Rather, I offered a prediction of a “likely”
scenario; i.e., “…if the bereavement exclusion is retained in DSM-5, patients like Mr. Smith
would likely be told, “You are just having a normal reaction to the death of your wife.†Probably,
no treatment would be offered, and none covered by insurance.”
I think you now understand why I indicated that insurance coverage could be a problem, even if the client/patient is offered “counseling” for the V-code, “bereavement.” But your comment makes it clear that I would have been on safer ground, had I written,
“…if the bereavement exclusion is retained in DSM-5, clinicians seeing patients like Mr. Smith
will still be encouraged to tell him that he is just having a normal reaction to the death of his wife.
This formulation, in turn, could discourage treatment for clinical depression, which may deprive Mr. Smith of essential professional care and services.”
I think we would both agree that empirical data are lacking, as to how the bereavement exclusion has actually functioned in clinical practice, though the total number of affected patients is probably small, relative to the total number of patients presenting with depressive signs and symptoms.
However, my rationale for eliminating the BE is not based primarily on an empirical claim re: how the BE has actually been implemented, or whether it has in fact deprived patients of essential services. I think that if you read the papers referenced in my blog,
you’ll see that my objection to the BE is based on
the lack of scientific foundation for it, in the first place; and upon recent evidence that undermines the BE’s validity, in the years since Dr. Clayton’s original studies were done.
Thanks again for your comments, and I hope my re-formulation more accurately conveys my position.
Best regards,
Ron Pies MD
“…deprive Mr Smith of essential professional care and services”. Those afforded by the average health care insurers of America these days, correct? That continue to require authorization of so many therapy visits for clinical indication, again am I interpreting your position accurately, yes?
Sounds like you are still making an argument to gain validation for approval for psychiatric care of grief that will only get more insurance payments if labeled depression, which is about medication if a psychiatrist is looking for rebursement.
You haven’t convinced me otherwise the DSM 5 is not about making acceptable deviations of the norm but just just pathologizing it.
Maybe you are just ignoring my early question, but if a person has no prior history of a mood disorder and then has symptoms of depression following an overt psychosocial stressor like a death, job loss, or other overt Axis 4 dynamic, are you really thinking MDD at the end of the eval hour?
To reply to Dr. Hassman:
1. I personally would like to see counseling for simple bereavement “covered” and paid for by insurers. There should be no need, nor any attempt, to depict bereavement-related grief as an Axis I disorder if the patient’s clinical picture doesn’t meet usual criteria for a major depressive episode.
Alas, I doubt insurers will ever agree to this. Fortunately, most grieving persons will find support from friends, family, pastoral care, etc.
2. Prior history of mood disorder is an important “clue” and a factor to be weighed carefully in evaluating the very earliest stages of post-bereavement depression (within 2-8 weeks of the death). So is family history of affective illness, as well as clues from the mental status exam, ancillary
screening tools such as the Beck Depression Inventory, etc. The judgment is a “gestalt”, based on
all these and other factors, and, of course, one’s own experience. It is not always an easy call, as I’m sure Dr. Hassman knows.
But, yes: if the patient meets full symptom/duration criteria for MDD, after recent bereavement (or other major loss), my working hypothesis–all other things being equal–is that this is MDD (major depressive disorder). I would follow up with the patient in another week, and see if my hypothesis was borne out.
Treatment might or might not be indicated at that point, and “treatment” could well be supportive psychotherapy, depending on a variety of clinical variables. [By the way, I would like to see the MDD criteria themselves “tightened”, by requiring 6 or 7 rather than 5 features–but that, too, is unlikely to be changed by the DSM-5]
I plan to take a break from this topic for a while, so I hope readers will have enough to mull for some time! Thanks to all who have written in.
Best regards,
Ron Pies MD
One thing to stands out to me, and I think it is kinda societal. Why does this hypothetical Mr Smith complain to DOCTOR about his feelings? Where is his family and friends?
I read that in the past people had more close people to confide in compared to today. Maybe this is also part of the problem we are seeing here.
Bravo. Thank you for providing some balance in the midst of all the furor. I wish the media would explore issues like this more in-depth and in a more balanced way. I appreciate the opportunity to read your point of view.
I will also take a break from this topic, but would like to ask readers to ponder these two points that came up from this thread:
1. Per the way Dr Pies worded it in his first reply on March 1, 9:25 PM, end of the first paragraph, if he is alluding that I am in this subgroup of psychiatrists he calls the “lightening rod for many simmering grievances”, is that a good or bad thing being in a subgroup challenging the decision making of those, who probably equally compose by number a subgroup, imposing their will on the profession as a whole? Life is perspective and interpretation, but, isn’t debate about issues like this healthy and responsible for the well being of the public that doctors basically serve?
2. I read today a commenter note that antidepressants are often underprescribed. Really, based on what diagnostic criteria leads to that conclusion? I don’t have the actually number at hand, but aren’t antidepressants by class the third most prescribed drug in America today, behind statins and probably antihypertensives? And furthermore, aren’t second generation antipsychotics like Seroquel and Abilify now jumping up the list, leading over categories like diabetic and GI medications? And we are to believe that if the prevalence of depression is about 6-9%, depending on who’s statistics you put stock in as accurate, that there are only about 10-12 million adults getting these prescriptions? Isn’t the actual number a lot higher than that, and remember, not everyone who is depressed is in treatment, nor are all antidepressant prescriptions written for depression alone, but if the number of scripts is higher than 20 Million, I think, is that reflecting underprescribing?
I do thank Dr Pies for answering my last comment’s question about diagnosing patients who present with depressive symptoms after a defining stressor is experienced. We’ll just have to hope that if the DSM5 creators have the public’s best interests at heart first and foremost, seeing this exclusion removed facilitates good care, not just maximizing profit margins for pharma and providers.
We’ll just have to take that leap of faith. The question is, how far is that chasm we are jumping over? To ponder further down the road, I guess.
The CDC study released in October 2011, based on data from the National Center for Health Statistics, showed 11% of the US population over the age of 12 — about 30 million people — were taking at least one antidepressant. 4.2 million are taking more than one.
The study is at http://www.cdc.gov/nchs/data/databriefs/db76.htm
Was reading about this issue at another blog and found this link. Read it and sincerely weep.
http://drjoanne.blogspot.com/2012/03/relativity-applies-to-physics-not.html
Dr. Pies.
If this mother doesn’t get over her grief in two weeks or whatever time you deem appropriate such as a month, she should be diagnosed with a mental illness?
http://www.wtae.com/r/30645251/detail.html
Western Psych Shooting Not First Tragic Death For Victim’s Family
Mary Schaab watched hours of news coverage before learning that her son had been killed in the violent crime — just like her only other child, Nancy, 26, who was shot during a domestic dispute in Plum in 2010.
On another issue, it seems that once someone has been diagnosed with a “MI” label, all behavior is seen through that lens. They are not allowed to have what are human reactions to losing a loved one because now you have decided that since they had a mood disorder in the past, then surely the grief reactions are due to their MI.
When is a person diagnosed with a MI label ever allowed to be human like everyone else? When are they free Dr. Pies?
You say you want to reduce stigma against people with mental illness but by labeling normal human behavior to losing a loved one, that is exactly what you are doing.
Dear Ms. Smith–
Please take a careful look at what I actually wrote in my article:
“At the same time, I strongly believe the DSM-5 should get rid of the arbitrary and misleading two-month guideline for normal bereavement. Grief, and its attendant anguish, sometimes lasts months or even years. By itself, there is nothing “disordered†in prolonged grief, if the person is largely able to function and flourish in life.”
The loss of a son or daughter–or a spouse–is an
unspeakable tragedy, and nobody is suggesting that we label the bereaved person’s grief as a “mental illness.” And, nobody should presume to tell the
grieving person to “get over” his or her grief after
a certain number of weeks or months.
It is when the ordinary grieving process gets “derailed” by a full-blown major depressive illness that professional help is needed.
Ronald Pies MD
MindFreedom International, a patient organization, is holding a protest against the DSM-5 at the American Psychiatric Association (APA) Annual Meeting in Philadelphia on Saturday, May 5, 2012.
Here’s why: “This peaceful protest exposes the fact that the DSM-5 pushes the mental health industry to medicalize problems that aren’t medical, inevitably leading to over-prescription of psychiatric drugs – including for people experiencing natural human emotions, such as grief and shyness,†said David Oaks, founder and director of MindFreedom International (MFI), which has worked for 26 years as an independent voice of survivors of psychiatric human rights violations. “We call for better ways to help individuals in extreme emotional distress.â€
It seems important to place this entire discussion in a broader context. In the United States, we have a major national problem with misdiagnosis and the overzealous prescribing of psychiatric medications. 92% of non-psychiatrist physicians admit in their own surveys that they do not have adequate training to prescribe psychiatric drugs. Unfortunately, many psychiatrists do little except prescribe psychiatric drugs and one also has to wonder about their competence when they sometimes place patients on 4 to 5 different drugs. One-third of the elderly residents of U.S. nursing homes are on psychiatric drugs, some on as many as 4-5. Children in institutional settings are over-drugged by physicians and psychiatrists. The diagnosis of ADHD in children tripled in the last 15 years and it’s not estimate that about 10% of American children have been diagnosed with ADHD and are on psychiatric drugs as treatment. The DSM-5, where all this discussion began, is not only eliminating the bereavement exclusion, which is likely to mean that thousands of individuals experiencing grief over the loss of a loved one will be placed on psychiatric medications, but numerous other DSM-5 proposed diagnostic categories are also highly problematic. For example: The number of criteria required for a person to be diagnosed with ADHD has been lowered; a new “disorder” called Mild Neurocognitve Disorder is likely to result in hundreds of thousands of elderly persons from the 78 million baby boomers who are reaching the older years, who are simply experiencing normal age-related cognitive decline, will be diagnosed as having this new, empirically unsubstantiated “disorder” and, you guessed it, placed on psychiatric drugs. Further, Prodromal Psychosis Syndrome, another invention of the DSM-5 Task Force, is directed primarily at teenagers who exhibit unusual behaviors and experiences and who therefore MIGHT be in danger of developing psychosis. These teenagers will be given a diagnosis of a mental illness and many will be treated, you guessed it again, with psychiatric drugs — although the research shows that 80% of such teenagers do NOT go on to develop psychosis and there is no evidence that “treating” the other 20% has any preventive effects. Yet another invention of the DSM-5 Task Force is Disruptive Mood Dysregulation Disorder (DMDD)which was designed to counter the “bi-polar disorder in children” fiasco that has occurred in recent years by giving physicians a more benign mental disorder to use with children who act out. Many believe that thousands of very young children will be diagnosed with DMDD and will be treated with — you guessed it again — psychiatric drugs. So it’s not just the “bereavement exclusion” that is of concern to thousands of clinicians; it’s also numerous other diagnoses that are likely to be used on hundreds of thousands of children and the elderly, as well as others. In a nation already reeling from the overprescription of psychiatric drugs, the DSM-5, unless changed before its publication in 2013, is likely to exacerbate this problem. Of course, pharmaceutical companies will make billions of dollars as a result of these new categories and the lowering of the diagnostic thresholds on others. But how many young children, old people, and others will suffer the dangerous and sometimes debilitating side effects of psychiatric drugs? This issue is not simply a scholarly discussion that, in the end, doesn’t matter much either way. Instead, the concerns about DSM-5 are a “social justice” issue. Anyone who cares about kids, the elderly, and others who will be given a diagnosis of “mental disorder” and treated with powerful psychiatric drugs which can have dangerous side effects, should be very concerned about what is happening.
Dr. Elkins certainly raises valid concerns regarding the prescribing of psychotropic medication, but that is not at issue in deciding whether or not to retain the bereavement exclusion. Our diagnostic categories should reflect the best available science, and the best interests of our patients–but our diagnostic criteria should not be gerrymandered to anticipate poor prescribing practices.
There are many legitimate questions raised in Dr. Elkins’ comments, regarding how broad or narrow our diagnostic categories should be. But this is not a matter of “misdiagnosis”; rather, it is a question of what degree of suffering and incapacity we, as a society, decide to accept as “normal” as opposed to “disordered.” Ultimately, this is an existential decision, not a matter of scientific discovery.
Finally, since most psychotropic medication is prescribed by general physicians, not by psychiatrists, our efforts must be redoubled in educating these physicians as to when to prescribe, when not to prescribe, and how best to prescribe. But all this has nothing directly to do with whether or not we should retain the bereavement exclusion.
Ronald Pies MD
With the debate that continues in our profession about the potential consequences of several potential new diagnostic topics for DSM 5, including this potential pre-psychotic designation, you really are going to say the bereavement exclusion issue should not be dragged into said debate, or vice versa?
Slippery slopes is a metaphor that fits. If you feel it appropriate to comment further, have you ever directly been involved with a patient who had “complicated bereavement issues” that did not do well being put on psychotropics? I have had several come to me with this response and were glad I redirected their treatment needs with psychotherapy, most by another provider, because, hey, their insurance would not pay for me to treat them with that intervention.
What does that say about the treatment process these days? I guess this issue is not going away, is it?
I appreciate Dr. Hassman’s comments and questions, and would offer these responses:
1. The bereavement exclusion is most certainly a legitimate topic for debate, and indeed, will be the focus of an international panel at the APA meeting in a few days. I have also proposed, in a blog on Psychiatric Times, that an independent, blue-ribbon panel (e.g., National Academy of Science) provide a consultative opinion to the DSM-5 work group, as regards the BE issue. But, in my view, the debate should stay focused on the BE itself, and not be subsumed in the fog of generalized complaints re: the DSM-5, pre-psychosis, psychiatric practice, etc.
2. I have not personally treated a patient who met proposed criteria for “complicated grief” (CG, which should not be confused with either “ordinary” uncomplicated grief, or with major depression, according to Kathy Shear and other experts on CG–see Zisook & Shear, World Psychiatry. 2009 Jun;8(2):67-74). I think it is too early to know what effect antidepressants have in most patients with
CG, and that we should keep an open mind until large,
controlled studies can be carried out. I am not aware of any controlled studies showing that antidepressants have an adverse impact on CG–or on post-bereavement major depressive symptoms.
Of course, there are undoubtedly grieving patients who were not provided appropriate “talk therapy”, but were given medication alone, and who subsequently experienced a worsening of their grief and/or depression. But I think we need to be very careful drawing any confident “causal” inferences from those cases. Interestingly, a recent review concluded that “Antidepressant medication may serve a useful adjunctive role in grief therapy completion and in reducing bereavement-related depression.” [Mancini et al, Curr Opin Psychiatry. 2012 Jan;25(1):46-51].
But again, I want to reiterate that ordinary, uncomplicated grief (in response to a death or any major loss)is not a “disorder” and needs no “treatment” other than love, support, and tincture of time.
Finally, I strongly believe that we need a broad and deep educational campaign to acquaint all clinicians with the substantive differences among ordinary grief, complicated grief, and post-bereavement major depression.
Best regards,
Ron Pies MD
Interesting to read in the most recent issue of The Psychiatric Times an article by Dr Pies about this very matter, and to see his Post Bereavement Phenomenology Inventory to allegedly differentiate between grief versus depression symptoms.
2 questions for Dr Pies, if interested in addressing this matter at this thread:
1. Is this an effort to profit on the matter if you are to trademark this inventory for clinicians to buy and use? and
2. Why do you focus every question first on depression features and not vary perhaps even/odd questions between grief and depression to not lead on participants to favor the first part of the question? It would not be hard to ask clinicians to score by question separate from the participant, so it could be more unbiased an inventory. Or, is the agenda to get participants to score more depressed?
My interpretation, and note just an interpretation, is that I worry you are siding on adding the bereavement diagnosis as part of the depression spectrum is there is a financial gain. If I am wrong, and I sense I am since you put the inventory in the article with no disclaimer, then I am at least curious to the second question above as how it is presented. You are probably involved in the APA convention thus will not see this until next week, but other readers coming here to ponder and investigate further as well.
The PBPI is in very preliminary form, subject to refinement, probably using a Likert rating scale for the various questions. The arrangement of the items is certainly also open to revision.
There are no restrictions placed on its use, and I have no intentions or plans to seek a “trademark”, copyright, etc. It will be enough to see enterprising researchers investigate the utility of the PBPI, and to find out that it is of help to clinicians and their patients.
Ronald Pies MD
In 2008, in The New York Times, Dr. Pies had an essay on grief titled, “Redefining Depression as Mere Sadness.” He started out with this case study: “Let’s say a patient walks into my office and says he’s been feeling down for the past three weeks. A month ago, his fiancée left him for another man, and he feels there’s no point in going on. He has not been sleeping well, his appetite is poor and he has lost interest in nearly all of his usual activities. Should I give him a diagnosis of clinical depression?” At the end of his essay he answered his question: “Until solid research persuades me otherwise, I will most likely see people like my jilted patient as clinically depressed, not just “normally sad†— and I will provide him with whatever psychiatric treatment he needs to feel better.” I wrote about this in a blog several years ago pointing out that this seemed to be an example of how psychiatry was turning normal sadness into grief. Regarding his piece in the Times I said Pies, “boldly states that using antidepressants to treat normal everyday sadness is perfectly acceptable and something that he has no problem with.” At the time Dr. Pies said I was crackpot and didnt understand the BE. Do other people think his essay in the Times was an example the extreme medicalization of human emotions or am I missing something?
Oh, and by the way, Dr Pies, here is another retort to your demand people use their real names at sites that have emotional content to them, not validating people be vicious and cruel, but, why sometimes they have full right to use aliases:
http://themoderatevoice.com/148052/terrorism-against-journalism-swatting-bloggers-and-other-harrassment/
Since my 2008 comments in the NY Times, dozens of pieces on the bereavement issue have been written. For those who want to read the most comprehensive recent review, please see the paper abstracted below.**
Re: Dr. Hassman’s comment: I agree that there are times when, in order to safeguard one’s safety, the use of a pseudonym or “nom de plume” is justified for bloggers. In fact, I recently said as much with regard to “Natasha Tracy”, whose blog I cited in a recent piece for Psychiatric Times. Sadly, we live in a time and place when writing can indeed prove a life-threatening activity!–Ron Pies MD
Depress Anxiety. 2012 May;29(5):425-43. doi: 10.1002/da.21927. Epub 2012 Apr 11.
The bereavement exclusion and dsm-5.
Zisook S, Corruble E, Duan N, Iglewicz A, Karam EG, Lanuoette N, Lebowitz B, Pies R, Reynolds C, Seay K, Katherine Shear M, Simon N, Young IT.
Source
Department of Psychiatry, University of California, San Diego, California; Veterans Affairs San Diego Healthcare System and Veterans Medical and Research Foundation, La Jolla, California.
Abstract
BACKGROUND:
Pre-DSM-III (where DSM is Diagnostic and Statistical Manual), a series of studies demonstrated that major depressive syndromes were common after bereavement and that these syndromes often were transient, not requiring treatment. Largely on the basis of these studies, a decision was made to exclude the diagnosis of a major depressive episode (MDE) if symptoms could be “better accounted for by bereavement than by MDE” unless symptoms were severe and very impairing. Thus, since the publication of DSM-III in 1980, the official position of American Psychiatry has been that recent bereavement may be an exclusion criterion for the diagnosis of an MDE. This review article attempts to answer the question, “Does the best available research favor continuing the ‘bereavement exclusion’ (BE) in DSM-5?” We have previously discussed the proposal by the DSM-5 Mood Disorders Work Group to remove the BE from DSM-5.
METHODS:
Prior reviews have evaluated the validity of the BE based on studies published through 2006. The current review adds research studies published since 2006 and critically examines arguments for and against retaining the BE in DSM-5.
RESULTS:
The preponderance of data suggests that bereavement-related depression is not different from MDE that presents in any other context; it is equally genetically influenced, most likely to occur in individuals with past personal and family histories of MDE, has similar personality characteristics and patterns of comorbidity, is as likely to be chronic and/or recurrent, and responds to antidepressant medications.
CONCLUSIONS:
We conclude that the BE should not be retained in DSM-5.
© 2012 Wiley Periodicals, Inc.