DSM5 in Distress

The DSM's impact on mental health practice and research

Grief vs Depression- One Last Word

How to make the distinction

I have written two previous blogs arguing strongly against a DSM5 suggestion that would make it much easier to diagnose Major Depressive Disorder in those who are grieving after the loss of a loved one. Drs. Ronald Pies and Sidney Zisook have provided two extremely well reasoned rebuttals - marshalling all the best reasons for removing the bereavement exclusion for Major Depressive Disorder (MDD) (see their detailed reply to my previous blog and also their comments on the Psychiatric Times website). But there remain a number of counter arguments that I believe are compelling enough to clearly disqualify this suggestion for DSM5.

Drs Pies and Zisook agree that the DSM requirement of only 2 weeks for the duration a major depressive episode is too short. They would prefer it be extended to
3-4 weeks to help avoid the problem with overdiagnosis.  I agree completely that requiring 4 weeks makes great sense for all milder depressions.  The short two week threshold is especially problematic among the bereaved - the only way it would make sense to diagnose MDD during bereavement would be if the symptoms were moderate to severe in intensity or last at least a month or were a recurrence of previous depressive illness.

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But Drs P and Z also admit that their desired change to lengthen the MDD duration will not happen in DSM5. When we put these two points together ( ie the need for a longer MDD duration requirement and that this will not be included in DSM5),  Drs. P and Z must admit that (even by their own reckoning)  removing the bereavement exclusion in the presence of the too short 2 week duration  requirement will necessarily result in overdiagnosis.  We can't wait for some future DSM to correct the fact that it is already far too easy to get a diagnosis of MDD and that the suggested change in the bereavement exclusion would further exacerbate this serious problem.

Would overdiagnosis be a big problem? Drs P and Z predict on the basis of one study that MDD will not be diagnosed very often in the bereaved. Based on my DSM IV experience, I am much more concerned. Our careful field trials on the suggested DSM4 changes for attention deficit disorder and autism convincingly showed that neither would dramatically raise prevalence rates - but "epidemics" of both soon followed.  Certainly, it is impossible to predict, with any precision, the impact of the suggested changes on MDD diagnosis in the bereaved, but great caution is necessary- especially since bereavement would become an  inviting new target for drug company marketing.

What are the implications for  treatment? Drs P and Z suggest that overdiagnosis would not cause great problems. Their initial treatment plans for most newly diagnosed "MDD" grievers would generally not include medication and it will be useful for such individuals to be under the care of the mental health system. This is problematic  in two ways. First, it would be naïve to extrapolate from their expert practice to what will happen in real life. As world experts in bereavement, Drs P and Z command our complete confidence were they to do the diagnosis and treatment under any system of diagnosis.  However, the  setting for diagnosing and treating MDD among the bereaved will often be a seven  minute appointment with a primary care physician who is not an expert in bereavement. Cognitive therapy is not widely available and has no promotional support- medication is easily available and heavily marketed. It follows, as day follows night, that in the real world most of those who are misdiagnosed will receive unnecessary medication, not possibly useful cognitive therapy.   

Then there is the cost/ benefit analysis of enrolling grievers in the mental health system. This is unquestionably a good idea for those with severe or risky symptoms. But I think it is unquestionably a bad idea for the vast majority of grievers who are experiencing 2 weeks of mild depressive symptoms that are perfectly compatible with normal grief. Medicalizing their reaction and treating it with medicine reduces the dignity of both the life lost and of the broken heart left behind. Most of these people will recover just fine without medical meddling and should have their feelings respected and normalized.
Of course, there are some grievers who have more severe or lasting symptoms that do indeed require medical attention. But  Drs P and Z are trying to solve what seems to me to be a non problem in handling this more urgent situation. DSM IV already includes a provision allowing for the diagnosis of MDD during the period of bereavement whenever the symptoms are severe enough to warrant immediate diagnosis and treatment. Criterion E in the DSM IV definition encourages the diagnosis of MDD within 2 months if the bereavement is "characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psycho motor retardation." This covers the P and Z concern about missing people who really need immediate treatment for their severe and risky symptoms. At the same time, it protects against the risk of the overdiagnosis of MDD among the average person experiencing the average expectable mild depressive symptoms of normal grief. If Drs P and Z would prefer to change or add symptoms to this list (perhaps some of those that have been described for melancholia or for complicated bereavement) this would be far safer than opening the floodgates in the way they have suggested.  

Drs P and Z hope that whatever  problems are created by their suggested loosened criteria can be handled by education. This too is naïve. In the real world, most of the "education" on bereavement will by financed by drug companies.

So, in summary, I believe that Drs Pies and Zisook are trying to solve a nonproblem (the need to diagnosis the severely depressed bereaved, which is already allowed in DSM IV) with a suggestion that  will create its own set of serious, new problems with overdiagnosis .

A final aside: I believe this type of risk/benefit debate should inform all of the changes suggested for DSM5. So far, the DSM5 Task Force has refused to engage in this way and we should thank Drs Pies and Zisook for taking up the gauntlet and presenting their arguments so skillfully.

 

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

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