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Thursday, 26 January 2012

Bereavement is Sad, but it's not a Depressive Illness

The status of bereavement in the next edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders ("DSM") is in the news again.

DSM IV, first published in 1994, defines "major depression" by a constellation of symptoms. Depressed mood and/or loss of pleasure capacity must be present, along with symptoms like sleep disturbance, fatigue, restless agitation or a feeling of being slowed down, loss of appetite and diminished ability to concentrate. The symptoms must represent a change from prior status and be present for at least two weeks. All of these symptoms may be present in normal bereavement.

Crucial for the current controversy, DSM IV included what has been called a "bereavement exclusion." The diagnosis of depressive illness is not made if:
The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
The DSM V committee that is working on criteria for major depression is proposing to drop the bereavement exclusion, largely based on research taken to imply that the exclusion isn't empirically supported. In a rather technical article, Jerome Wakefield and Michael First from NYU and Columbia, pick apart that research and argue that the exclusion should be retained.

This isn't a matter of arcane definitions and paperwork. Dropping the exclusion will lead to an epidemic of overdiagnosis of depressive illness when what's really happening is painful grief. Overdiagnosis will have harmful consequences, including:
  • Medication will often be prescribed. While anti-depressants are relatively well tolerated, all medications can cause harm through side effects.
  • Grief typically resolves over time. When this happens, at least some of those taking medication will attribute their improvement to the drug. This can alter self image - "I fell apart when X died - thank God the medicine and the doctor got me out of it."
  • Many will stay on the drug and attribute their ongoing wellbeing to its continued use, at the cost of recognizing their own capacity to recover from a painful loss and the potential side effects from long term drug use.
  • Even if no harm accrues from diagnosis and medication use, unnecessary interventions will add unnecessary costs for individuals and the wider community.
  • And, for all those suffering from normal, though painful, grief, medicalization of the condition may distract from normal healing processes - tears, preoccupation with the loss, rituals, and more.
Dr. Kenneth Kendler, a member of the DSM V work group, argues that these fears aren't warranted:

...diagnosis in psychiatry as in the rest of medicine provides the possibility but by no means the requirement that treatment be initiated. Watchful waiting is important tool for all skilled clinicians. As a good internist might adopt a watch and wait attitude toward a diagnosable upper respiratory infection assuming that it is unlikely to progress to a pneumonia, so a good psychiatrist, on seeing an individual with major depression after bereavement, would start with a diagnostic evaluation...As with the psychiatric response to the other major stressors to which we humans are all too frequently exposed, good clinical care involves first doing no harm, and second intervening only when both our clinical experience and good scientific evidence suggests that treatment is needed.  
"Watchful waiting" is indeed an important tool for skilled clinicians. If clinicians, the public, and pharmaceutical companies, all conducted themselves in accord with Dr. Kendler's wise precepts, the bereavement exclusion wouldn't matter.

But, alas, this prudent approach to clinical practice is in too short supply in American medicine. We're an activist society. Watchful waiting in the face of a serious diagnosis is almost un-American. That's why "watchful waiting," the wisest approach for many men with early prostate cancer, has had to be rebranded as "active surveillance."

If the bereavement exclusion is dropped, it's only a matter of time until media will be flooded by pharmaceutical advertisements targeted at individuals who have suffered loss and their well intentioned families.

Since the American Psychiatric Association agrees with Dr. Kendler that "good clinical care involves first doing no harm," DSM V should retain the bereavement exclusion!


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