Bye Bye Bereavement Exclusion?

A NYT op-ed reports that the APA is close to either dropping the bereavement exclusion from the Major Depression diagnostic criteria or adding something like Bereavement Related Depression.

I too find this troubling and see no way to characterize this other than an attempt to pathologize a normal human process.

One of the advocates left a comment on a post a couple of years ago. One of the links he left was a counter argument against the concerns identical to those expressed in this NYT op-ed. Among his counter arguments was this:

There are no convincing data showing that the bereavement exclusion for the diagnosis of major depression protects against “pathologizing” normal grief,

Really? The title of his response is “DSM5 Criteria Won’t “Medicalize” Grief, if Clinicians Understand Grief“. Isn’t the DSM a manual of DISORDERS?

Does someone who is grieving have a disorder? Even if they have the same symptoms as someone with a disorder? Is context unimportant? Does someone who experiences intense anxiety in the days following a traumatic event have an anxiety disorder until proven otherwise? How about a patient detoxing from alcohol or benzodiazapines?


Symptoms do not equal diagnosis.

UPDATE: What does this mean? It does not mean we ignore those symptoms. We can respond to the person’s suffering without treating them as though they are ill in some way. We can also recognize that the vast majority of grieving people will get their needs met from their family and community and that these natural supports should be the first line response. We can recognize them as at risk for depression and intervene if they are not experiencing gradual relief of their depressive symptoms.

One thought on “Bye Bye Bereavement Exclusion?

  1. Hi, Mr. Schwartz: I appreciate your concerns regarding the possible elimination of the bereavement exclusion (BE), and your citation of the short piece by Dr. Zisook and myself. You will find a much more detailed explanation of why Dr. Zisook and I favor dropping the BE in J Clin Psychiatry. 2010 Jul;71(7):955-6.Bereavement, complicated grief, and DSM, part 1: depression.(Zisook S, Reynolds CF 3rd, Pies R et all). Readers can also learn more about the background issues by going to:…/is-grief-a-mental-disorder-no-but-it-may-become-one.In brief: I completely agree with you that "ordinary" (what I call "productive") grief following loss of a loved one is not a "mental disorder" and does not require treatment. The question is: what about patients who present to us showing the full panoply of major depressive disorder (MDD) symptoms–i.e., they meet full DSM MDD criteria–a few weeks after or within 2 months of a recent loss (death of a loved one)? Does the loss per se nullify the diagnosis of MDD? We argue that there is no convincing data to support such nullification of MDD; the ICD-10 takes the same position, in contrast to the DSM-IV. Specifically, there are no convincing data showing that given 2 people, both meeting full DSM criteria for MDD, the one with recent bereavement will differ in any significant way from the one with no bereavement, in terms of clinical course, impairment, suicide risk, or response to treatment. Most studies show the opposite; i.e., the two people are quite similar in all these respects. You are right that symptoms alone do not constitute a diagnosis, and that "context" is important–sometimes. To take your example of anxiety following alcohol withdrawal: we have both pathophysiological and clinical reasons for asserting confidently that a patient with anxiety secondary to alcohol withdrawal will run a totally different course, and have different treatment responses, than someone with a primary generalized anxiety or panic disorder. We do not have such evidence for individuals presenting with a full MDD symptom picture in the context of recent bereavement. That said, definitive studies (prospective, controlled studies of MDD with and without recent bereavement) have yet to be done. Finally, in gauging the pros and cons of diagnosing MDD in the context of recent bereavement, we must also consider the risk of "missing" a case of MDD–a condition in which there is at least a 4% mortality rate, due to suicide. Both Dr. Zisook and I believe the risks of "over-diagnosing" grief as MDD, and getting the person involved in professional treatment (psychotherapy, perhaps medication) are far fewer. Best regards, Ronald Pies MDTufts U and UpstateMedical University

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