Shedding Light on Grief, Major Depression, and the Bereavement Exclusion

The removal of the so-called “bereavement exclusion” (BE) from DSM-5 was one of the most difficult and controversial decisions the DSM-5 work groups made, and many clinicians continue to find the distinction between ordinary grief and major depression confusing. However, said Ronald W. Pies, MD, at the APA 2014 Annual Meeting, grief and depression are distinct constructs, despite some overlapping features, such as sadness and insomnia.

Pies, a professor of psychiatry at SUNY Upstate Medical University and Tufts University, noted that major depressive syndromes occurring shortly after the death of a loved one (bereavement) do not differ substantially in symptoms, course, impairment, outcome, or treatment response from major depression in any other context, or occurring “out of the blue.” Pies stated that removing the bereavement exclusion was justified by the best available studies and did not amount to “medicalizing grief,” as some have argued. However, he noted that definitive, controlled studies have yet to be done. “We need studies that compare recently bereaved, depressed patients with non-bereaved depressed patients, while controlling for other important variables, such as initial severity of depression, presence of melancholic features, number of prior depressive episodes, etc,” Pies told Psychiatric Times.

Pies pointed out that the DSM-5 criteria for major depressive disorder (MDD) merely ensure that the subset of persons who meet the full symptom-duration-severity criteria for major depression within two weeks after the death of a loved one will no longer be excluded from the set of all persons with MDD. As Pies put it, bereavement “does not immunize the patient against major depression, and often precipitates it.”

Disqualifying a patient from a diagnosis of major depression simply because the clinical picture emerges after the death of a loved one risks denying the patient potentially life-saving interventions, Pies said. The “exclusion” principle also fails to recognize that MDD is often highly over-determined, involving multiple, interacting causes; e.g., subclinical hypothyroidism, recent job loss, etc. Even in the context of bereavement, it is still difficult to tease out which factors are “causal” in the depressive episode. Furthermore, the DSM-IV’s provisions for overriding the bereavement exclusion were potentially misleading, Pies said. For example, the DSM-IV would not have applied the bereavement exclusion to overtly suicidal patients. But Pies noted that not all seriously depressed patients will acknowledge being suicidal, and the risk of suicide is not merely a matter of overt suicidal ideation; rather, research shows that overall severity of depression and the presence of hopelessness also raise the risk of eventual suicide.1

Pies noted that if the psychiatrist believes the patient’s clinical picture reflects normal, bereavement-related grief, the “V Code” of “Uncomplicated Bereavement” (V62.82) may be used. In some cases, prudence may warrant a period of “watchful waiting”-beyond the 2-week minimum required for a diagnosis of major depressive disorder-in order to assess the trajectory of the patient’s signs and symptoms. Finally, Pies said, not all bereaved patients diagnosed with a major depressive episode will require antidepressant treatment, since mild-to-moderate cases may respond to psychotherapy alone.

Disclosures:

Ronald W. Pies, MD is Professor of Psychiatry and Lecturer on Bioethics at SUNY Upstate Medical University, Syracuse, NY; and Clinical Professor of Psychiatry at Tufts University School of Medicine, Boston. His most recent book is, Psychiatry on the Edge (Nova Publications, 2014.).

References:

1. Brown GK, Beck AT, Steer RA, Grisham JR. Risk factors for suicide in psychiatric outpatients: a 20-year prospective study. J Consult Clin Psychol. 2000;68:371-377 .