DSM5 in Distress

The DSM's impact on mental health practice and research

Normal Grief vs Depression In DSM5

How to avoid medicalizing grief.

The recently posted draft of DSM5 makes a seemingly small suggestion that would profoundly impact how grief is handled by psychiatry.  It would allow the diagnosis of Major Depression even if the person is grieving immediately after the loss of a loved one. Many people now considered to be experiencing a variation of normal grief would instead get a mental disorder label. For example, take the case of a man whose spouse unexpectedly dies. For two weeks after the death, he feels sad, doesn't want to go to work, loses his appetite, has trouble sleeping and concentrating. Currently, this is normal grief. The DSM 5 suggestion would have this be major depression.

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Undoubtedly, this would be helpful for some people who would receive much needed treatment earlier than would otherwise be the case. But for many others, an inaccurate and unnecessary psychiatric diagnosis could have many harmful effects. Medicalizing normal grief stigmatizes and reduces the normalcy and dignity of the pain, short circuits the expected existential processing of the loss, reduces reliance on the many well established cultural rituals for consoling grief, and would subject many people to unnecessary and potentially harmful medication treatment.

Grief is an inescapable part of the mammalian experience and a necessary correlate of our ability to attach  so strongly to other people. Though grief is universal, there is no one right to grieve. Different cultures prescribe a wide variety of different behavioral and emotional reactions and rituals. Psychiatry needs to tread lightly and have compelling reasons before encroaching with its own rituals  on such time honored and usually effective practices.

 Within a given culture, normal individuals also vary enormously in the content, symptoms, duration, and impairment of their grief and in their ability to draw consolation and sustenance from others.  There is no bright line separating those who are experiencing loss in their own necessary and particular way from those who will stay stuck in a depression unless they receive specialized psychiatric help.

The numbers on each side of the normal/mental disorder divide are probably very lopsided-most people who grieve do not have a mental disorder. Ever since the dawn of man, humans have had frequent occasions to grieve. Almost all of us come to terms with the loss and the altered conditions of a new life without the benefits of psychiatry-and do just fine on our own. The change in DSM5 would attempt to identify the very small percentage of people who have a complicated grief that goes beyond the average expectable in severity, symptom pattern, and duration - those who would not remit as part of the natural evolution of their grief. But when you use a big shovel to capture a small needle in the haystack, what you mostly get is hay. Any change in the way DSM5 defines grief may gather a very large proportion of false positives who would do better avoiding psychiatric help.

The rationale given by DSM5 for its radical proposal is brief, cryptic, and fails to provide anything like a risk/benefit analysis of  potential effects. DSM5 states that there is no evidence that the depression triggered by the stress of losing a loved one is any different than  depression triggered by other severe stressors (such as job loss or divorce)- thus claiming that there is no justification to withhold the diagnosis of major depression after a loss. This  rationale places the burden of proof in the wrong direction.  DSM5 should make so consequential a change only after a careful and considered evaluation proves with compelling evidence that it will do more good than harm.

  Such evidence is simply not available.  The research in this area is interesting but in very early development and we don't know many essential things. We have no idea how any proposed criteria set would work in the general population.  What percentage of grieving individuals would get the diagnosis (especially once drug companies raise awareness of it)? Among the people who would be diagnosed, we don't know what percentage truly need psychiatric help, what percentage would do better without it.

Pies and Ziskind (in a recent commentary in Psychiatric Times) have  gone far beyond the meager DSM5 rationale to present the strongest possible case for allowing the diagnosis of Major Depression in grief situations. They cite several lines of argument:
1)There is a clinical need- some individuals have severe, complicated grief that looks just like severe Major Depression and does not get better spontaneously. The longer that diagnosis and treatment are delayed, the greater their suffering, impairment, and risks (eg job loss, injured relationships, lowered treatment response, suicide).
2)The loss of a loved one is not essentially different from the many other serious stressors that abound in life.  
3)It is impossible to predict the future misuse of the DSM5 system so we should make decisions based only on the best possible science.   
4) The criteria for complicated grief could be tightened to reduce false positives.( They suggest two useful ways described below and I add two others).
5)Education can solve the problem of false positive diagnosis and the risk of providing medicine in milder cases when time, support, and/or psychotherapy would be more indicated.
    
The  excellent proposal made by Pies/Ziskind to reduce false positives could be strengthened even further if two additional exclusions were added to the  two(#'s 1and 2 below) that they   suggested . The entire package differentiating grief  from depression would require:
1)An extended duration of one month.
2)A particularly severe presentation that  includes some combination of unreasonable guilt, worthlessness, hopelessness, self loathing, anhedonia, a focus on negative memories of the departed, alienation from others, and inability to be consoled.
3)To recognize the different cultural expressions, the diagnosis of depression would not be made if the person's grief is within  cultural norms.
4)An exclusion could be added that would take into account the person's own past experience of grief and its previous outcomes.  If the individual previously had severe grief symptoms, but recovered spontaneously (without going on to a major depression), this would suggest they are now grieving their own way and do not require diagnosis or treatment.

DSM5 has made many poorly thought through suggestions that can be fairly easily dismissed. Though I continue to disagree with the  Pies/Ziskind proposal, it is reasonable and deserves serious consideration. Here are the opposing points:
1) Re clinical need: In appropriate cases displaying  clinically significant impairment, distress, or risk, the diagnosis Depression Not Otherwise Specified covers their false negative problem.
2)I believe there is a difference between losing a loved one and most other life stressors. This  explains why grief is the universal target of communal healing rituals.  It would be unfortunate for psychiatry to prematurely roam into problems usually better handled by family and other cultural institutions. Cultural biases would be very hard to surmount in making this diagnosis.   3) My disagreement with Pies and Ziskind is strongest on this point. All decisions for DSM5 should follow the injunction-"First Do No Harm."Although it is impossible to predict precisely how any DSM5 change will eventually play out once the manual is in general use, that doesn't reduce DSM's responsibility for the problems that occur, even if they are unintended. All potential risks have to be thought thru and factored into a thorough risk/benefit analysis.  The argument that we should just go to where the science takes us ignores that the science is (as they point out) not definitive, is subject to different interpretations, and is not readily generalizable from research to real world settings. Once the genie is out of the bottle and DSM5 makes it easy to diagnose depression in grief situations, this could easily become an industry propelled fad diagnosis.
4) The tightened criteria would help reduce, but certainly not eliminate, the grave potential harm caused by the massive misidentification of false positives.
False positives and excessive treatment are not be a problem for skilled and cautious clinicians (like Pies and Zisook), but in the real world most of the prescriptions will be written by primary care physicians who have six minutes with each patient, don't know the fine points of the criteria sets, and want the fastest solution.  
The false positive problem is too unknown and potentially far too large to ignore. At a minimum, there would need to be field trials to determine prevalence, reliability, false positive, and false negative rates. I doubt that DSM5 has the time, money, and skill to pull this off.
5) it would be naïve and unwise to rest our hopes that any educational  program  would reduce over diagnosis and the overprescription of medication in grief situations. To the contrary, most of the education would go the other way. The drug companies devote enormous resources to "educating" physicians to be quick on the draw in prescribing medication  

I respect the arguments made by Pies and Ziskind  and believe they  work well when applied by experts like them. My worry is the misuse of even reasonable ideas in the real world  situations where most diagnosis and treatment is done. Loose diagnostic and treating habits could lead to the widespread medicalization of grief well beyond what Pies and Ziskind would themselves recommend. There are two ways of avoiding this. The first is to keep things as they are and not to diagnose Major Depressive Disorder in the first two months after the loss of a loved one.

The second is for DSM5 to allow for the diagnosis of complicated grief but with a  criteria threshold set high and including all four protections against false positives outlined above. As recommended by Pies and Ziskind, there should also be a  physician and public education campaign normalizing normal grief and  sharply delimiting the small group of grievers who need psychiatric
help.

Weighing the pluses and minuses, my call is to keep things as they are and not risk an "epidemic" of psychiatric grief.  

 

Allen Frances, M.D., was chair of the DSM-IV Task Force and is currently professor emeritus at Duke.

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