Debate: Let the Bereavement Exclusion in DSM-5 Die

The DSM-IV bereavement exclusion (BE) is a source of consternation-something to squint the eyes and cock the head at, and create wonder (See: "Ringing the Bell to Save the Bereavement Exclusion"). It is an anachronism, a failure to apprehend the terms “biopsychosocial” and “stress-diathesis,” based on a false dichotomy, an idea that academicians and philosophers might ponder, but not experienced clinicians.

Apart from purely academic questions addressed in studies summarized elsewhere, the BE never enters my thinking except as a contextual marker for a broad and proper description of illness that precedes holistic treatment planning.¹ It is not a deciding factor, or rule-out. It is of Axis IV importance, and not merely relegated as such.

I write this as one in the midst of bereavement, having lost my dear mother several months ago. I moved my family to North Carolina 9 years ago for the express purpose of joining my extended family here. We made the decision as a part of a mid-life “course correction.” Enjoying each other and supporting each other during the last years of my parents’ lives was of prime importance. My father died before we could make the move. My mother lived independently for 8 years-and we lived it to the hilt. During the last year of her life (in rehab facilities and briefly in a nursing home) we were never closer.

I still avoid driving by the nursing home. I still wake up at night occasionally tearfully thinking of her. I cook a lot of pot roasts in the old cast iron Dutch oven she made famous. I am converting a home office to a guest bedroom filled with family memories. I am not ill. I am grieving. It doesn’t look like illness. It doesn’t need to be treated like illness. I can’t believe anyone would mistake it for illness, especially an experienced clinician. But if I were ill and grieving, I would expect my health care providers to understand that the 2 concepts are not mutually exclusive, and I would expect them to offer help for my illness . . . all of it.

Part of my practice is in a mood disorders clinic in a family practice residency. I wish everyone could have a similar opportunity to assess and treat patients. This team approach, continually balancing the views of the psychopharmacologist, psychologist, social worker, family practice resident, and patient is the clinical Promised Land. During each intervention, we strive to leave no stone unturned, no problem unaddressed-and we keep each other honest. Often as not, it is the psychotherapist in the group who calls attention to a biological vulnerability and the opportunity to offer improvements in affective stability and emotional resilience with skillfully prescribed medication. The psycho-pharmacologist (me) gets to practice therapeutic conversation in the presence of passionate teachers. Patients hear thoughtful clinicians and begin to understand themselves and their situations as complex systems that may benefit from a variety of combined treatments.

All this is to say that I cannot remember a single instance in this setting where the BE saved the day, preventing the unnecessary use of medication for a nonillness. In situations in which previous ill episodes were absent, symptoms were mild, and cognition and function were preserved, we would always choose the path of supportive and cognitive psychotherapy, and bibliotherapy or other nonpharmacological means as primary interventions. However, in patients with severe symptoms or those with documented histories of Axis I illness, we would never ignore the reality that intact affective control systems are a requirement for successful negotiation of grief. And we would never sacrifice the patient’s life on the altar of our academic egos. We are clinicians first.

To the extent that DSM-5 is an evidence-based document, the BE should die or, perhaps preferably, take its proper place of importance in Axis IV. All passionate 5-axis egalitarians who understand grief in the broad context of depressive illness can now say, “Amen.” We are clinicians.

References:

1. Lamb K, Pies R, Zisook S. The bereavement exclusion for the diagnosis of major depression: to be, or not to be. Psychiatry (Edgmont). 2010;7:19-25.