Expanding the Boundaries of Major Depressive Disorder in DSM-5: The Removal of the Bereavement Exclusion

doi:10.4236/ojd.2014.31004

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Open Journal of Depression

2014. Vol.3, No.1, 9-12

Published Online February 2014 in SciRes (http://www.scirp.org/journal/ojd) http://dx.doi.org/10.4236/ojd.2014.31004

Expanding the Boundaries of Major Depressive Disorder in

DSM-5: The Removal of the Bereavement Exclusion

H. Russell Searight

Department of Psychology, Lake Superior State University, Sault Sainte Marie, USA

Email: [email protected]

Received November 19th, 2013; revised January 3 rd, 2014; accepted January 13th, 2014

Attribution License, which pe rmits unrestricted use, distribu tion, and reproduction in any medium, provided the

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Introduction

The recent publication of the Fifth Edition of the Diagnostic

and Statistical Manual of Mental Disorders (DSM 5; American

Psychiatric Association, 2013) appears to have triggered more

controversy than its predecessors. The DSM 5, the first signifi-

cant revision of this internationally accepted system for psychi-

atric diagnosis in the past 20 years, has been the subject of

much pre- and post -publication criticism and debate—much of

which has occurred in the popular press (Satel, 2013). One of

these controversies centers on the distinction between major de-

pressive disorder (MDD) and bereavement. Technically, “bere-

avement” refers to an individual’s state after losing a loved one

while “grief” describes the individual’s psychological reaction

to the loss. The two terms are often used interchangeably in the

literature—a convention which will be followed herein.

Historically, previous DSM guidelines have included a pro-

viso that clinicians should not diagnose a patient with MDD

when there was evidence that the symptoms occurred immedi-

ately after the death of a loved one. Specifically, while the

symptoms for MDD as well as their duration, have remained

essentially the same in the transition from DSM-IV-TR to

DSM-5, the guidelines for excluding a diagnosis of MDD in the

context of bereavement have been removed in the recent revi-

sion. In the DSM-IV-TR, there was a clear directive at the end

of the list of MDD’s diagnostic criteria to avoid diagnosing

MDD if symptoms were better accounted for by bereavement

(American Psychiatric Association, 2000). In the previous sys-

tem, even if the specific criteria and time duration had been

fulfilled for a major depressive episode (MDE), the diagnosis

was not given if symptoms were temporally associated with the

death of a loved one and were of less than two months’ duration.

The rationale for the exclusion, though not well articulated in

the DSM, has generally been assumed to avoid placing a medi-

cal diagnosis on a normal, albeit emotionally difficult, life tran-

sition. In addition, grief research had indicated that MDE sym-

ptoms and a bereavement-related reaction overlapped conside-

rably (Wakefield, 2011). It was assumed that when associated

with bereavement, depressive symptoms would dissipate in se-

veral months without formal treatment. These assumptions have

been called into question—a factor likely associated with the

recent bereav ement exclusion.

While not specifically stated in the DSM 5, research evi-

dence has accumulated over the past two decades calling the

bereavement exclusion into question. Investigators have found

few differences in symptoms between recently bereaved indivi-

duals and those with MDE (Horwitz & Wakefield, 2007). Ad-

ditionally, there have been a small series of studies indicating

that bereaved individuals may benefit from antidepressant me-

dicati on. Whi le the DSM-5 i ncludes an extended footnote about

how to distinguish MDE from bereavement, the note concludes

with an admonition to clinicians to be aggressive in diagnosing

depression even in the context of a recent loss. Critics of the

DSM-5 have suggested that the decision to drop the bereave-

ment exclusion reflects the medicalization of distress, a grow-

ing norm in Western culture to translate psychosocial distress

into medical symptoms with a pharmacological treatment. These

critics view the removal of the bereavement exclusion as part of

an economically fueled movement to expand the boundaries of

psychopathology to increase the market for pharmacotherapy

(Frances, 2013; Greenberg, 2013). From a broader philosophi-

cal perspective, there are concerns that bereavement-related di-

stress may be meaningful for the survivors and should not be

artificially dimin ished with psychopharmacologic balm (Frances,

2013; Elliott, 2000).

DSM-5 Recommendations for Distinguishing

Grief from MDD

The DSM-5 contains an extended footnote about distingui-

shing grief from MDD. While acknowledging that dysphoria-

may be part of grief, this mood state is seen as much more per-

sistent and constant in MDD compared with bereavement. Gri-

eving individuals are likely to experience more variability in

mood including periods of happiness alternating with intense

sadness triggered by thoughts of the deceased. The course of

grief also differs with sadness becoming less intense in days to

weeks while MDD’s adverse mood states are much more ex-

tended. Worthlessness and diminished self-esteem, while com-

mon in MDD, are generally absent in grief. DSM-5 acknowl-

edges that both MDD and bereavement may be associated with

suicidal ideation; however, the underlying motivation differs. In

MDD, suicidal thoughts are commonly associated with feelings

of worthlessness or as a mechanism to relieve emotional suf-

fering. By contrast, suicidal thinking is less common in bere-

avement and when it occurs is usually associated with a desire

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H. R. SEARIGHT

to join the deceased. The DSM-5 authors caution diagnosticians

to be aware of the likelihood of MDD even in the context of in-

terpersonal loss.

While some of these distinguishing criteria seem relatively

clear, the ability to discriminate bereavement’s “feelings of

emptiness and loss” from MDE’s “persistent depressed mood

and …inability to anticipate happiness or pleasure” (American

Psychiatric Association, 2013; p. 161), is likely to demand

more of the clinician’s acumen and time. Given that most pa-

tients with MDD are diagnosed and treated by primary care

physicians (Callahan & Berrios, 2005), it may be difficult to

distinguish these subtleties in a standard 10 - 15 minute office

visit particularly when there are comorbid medical issues.

Bereavement Does Not Differ from Reactions

to Other Life Stressors

The removal of the bereavement exclusion in the DSM-5 has

been attributed to several research findings in the past 20 years.

Historically, the DSM, while not making it a formal diagnosis,

has included discussion of bereavement. For example, DSM-

IV-TR describes the difference between complicated bereave-

ment which triggers an episode of MDD and symptoms asso-

ciated with loss that resolve within two months which are not

formally diagnosed (American Psychiatric Association, 2000).

Wakefield and colleagues completed a series of studies and

concluded that there is little support for the bereavement exclu-

sion. Comparisons of persons fitting DSM IV-TR’s description

of complicated bereavement found little difference in symp-

toms or severity of symptoms from those with uncomplicated

bereavement (Wakefield, Schmitz, First, & Horwitz, 2007). Un-

like MDD which is often chronic, only 10% - 12% of persons

who are bereaved still show symptoms of MDD at one year

following the loss (Wakefield & Horwitz, 2007). It is estimated

that without the bereavement exclusion, approximately 20% -

40% of bereaved individuals would be diagnosed with MDD

(Horwitz & Wakefield, 2007).

Wakefield et al., (2007) provide additional evidence support-

ing the view that the MDD’s diagnostic boundaries should be

contracted rather than expanded. In comparative analyses of

large samples of persons with depressive symptoms, they found

no differences in the actual symptoms or their severity in re-

sponse to death of a loved one versus in response to other loss-

es such as sudden unemploymentor, marital dissolution. Based

upon these findings, Wakefield and colleagues (2007) have

argued that when MDD symptoms are associated with any type

of significant life event, a mood disorder diagnosis should not

be given. Wakefield’s (2011) major criticism of the DSM crite-

ria is that they fail to take into account the symptoms’ context

and the bereavement exclusion should be extended to emotional

reactions to these other life events-thus reducing the prevalence

of MDD.

Conversely, however, these research findings and the ac-

companying reasoning can be used to support the view that

bereaved individuals should receive a diagnosis of MDD. Wa-

kefield and colleagues found that the same complement of de-

pressive symptoms characterizing bereavement were no differ-

ent than symptomatic responses to other life events such as an-

ticipated work lay-off or learning of a romantic partner’s infi-

delity (Horwitz & Wakefield, 2007). Since individuals experi-

encing depressive symptoms associated with other life stressors

would, according to current standards, be diagnosed with MDD

if symptoms were present for two weeks, bereaved individuals

should receive the diagnosis as well. With the removal of the

bereavement exclusion, Horwitz and Wakefield (2007) predict

that one-third to one-half of bereaved individuals will meet cri-

teria for MDD during the first month immediately following the

loss

Pharmacotherapy of Bereavement

Treatment of grief with psychotropic medication has been

studied in small samples—often without the benefit of double

blind placebo controlled designs. Another limitation of this re-

search is that the conditions treated in these studies are some-

what heterogeneous with complicated grief, bereavement-re-

lated MDD and bereavement alone included. Early studies, us-

ing tricyclic antidepressants (TCAs) demonstrated some reduc-

tion in depressive symptoms but a more modest effect for grief

intensity. While the majority of studies are simple prepost inve-

stigations with small sample sizes, Zisook and colleagues (2001)

compared the effects of an 8 week trial bupropion on a group of

patients compared with an intention-to-treat group. Both groups

demonstrated significant improvement in depressive symptoms

with a more modest reduction in grief. In a comparison of psy-

chotherapy with and without medication, Reynolds and col-

leagues (1999) found the most favorable outcome on depressive

symptoms for combined interpersonal psychotherapy and nor-

tiptylene (69%) with nortiptylene alone (56%) demonstrating

superiority over placebo groups. However, neither of these ac-

tive treatment groups demonstrated significant reductions in

grief intensity.

Studies involving SSRIs while fewer, suggest that these me-

dications may have greater impact on grief as well as depres-

sion. For example, in an open-label trial of escitalopram, re-

sponse to medication was 83% for depressive symptoms but

only 45% for symptoms of complicated grief (Hensley, Slono-

minski, Uhlenhuth, & Clayton, 2009). A smaller trial of 16

weeks of escitalopram found a 38% reduction in grief intensity

after 16 weeks. Of not e, however, the correspondi ng intention to

treat group demonstrated a 24% reduction in grief (Bui, Nadal-

Vicens, & Simon, 2012; Shear, Fagiolini, Houck, et al., 2006).

In sum, while not an exhaustive review of research in this

area, findings to date suggest that medication for bereavement

may lead to more rapid resolution and/or substantially reduce

depressive symptoms. However, from a quantitative perspective,

pharmacotherapy appears to have less pronounced impact on

the experience of grief.

Is Grief Necessary?

Arguing that bereavement is not a psychiatric disorder,

Frances (2013) and others have noted that grief is a common

behavioral reaction that occurs among non-human mammals.

For example, macaques deprived of group membership exhibit-

ed a stereotypic behavior pattern that differed from those with

normal social contact. Of particular interest was the finding that

these socially deprived macaques exhibited diminished seroto-

nin activity in the prefrontal brain region (Bui, Nadal-Vinces, &

Simmon, 2012; Fontenot, Kaplan, Manuck, Arange, & Mann,

1995). Evolutionary psychologists have generated multiple the-

ories about grief. Outward changes in behavior may elicit sup-

port from others. Archer (1999) suggests that grief is the neces-

sary outgrowth of the evolutionary advantage of social attach-

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H. R. SEARIGHT

ment.

While noting the commonality of the grief response across

species, Frances (2013) also raises moral and philosophical

objections to dia gnosing gri eving individuals with MDE. Frances

argues that there is something inherently offensive in reducing

grief to a disease: “Medicalizing grief reduces the dignity of the

pain, short-circuits the expected existential processing of the

loss, reduces reliance on the many well-established cultural ri-

tuals for consoling grief, and would subject grievers to unne-

cessary and potentially harmful medication” (Frances, 2013: p.

187). Medicalizing grief both impugns the integrity and “dig-

nity” of the survivors’ emotional experience, but also is disres-

pectful to the life that was lost (Frances, 2013). Grief and be-

reavement rituals are long-standing responses that have impor-

tant meaning in their specific culture. In some cultures such as

Japan, intense contemplation and melancholia have been seen

as signs of morally superior character (Kitanaka, 2012). MDE,

as a disorder is only beginning to be recognized in Japan (Kita-

naka, 2012).

Treating Grief: Harm or Enhancemen t

The implicit corollary of converting grief to MDD is that

within American medicine, diagnoses are inextricably tied to

available treatment. However, if bereavement can be treated

with pharmacotherapy, should it be?

Before further discussion of the moral side of this issue, it is

worthwhile to consider the impact of implicitly diagnosing and

overtly treating everyone exposed to a stressful live event.

Critical Incident Stress Debriefing (CISD), typically adminis-

tered as a group intervention, to persons exposed to life-threa-

tening traumatic events such as first responders, continues to be

commonly used, and often mandated. However, data from mul-

tiple studies suggest that the iatrogenic affects often outweigh

any benefit from CISD (Lohr, Hooke, Gist, & Tolin, 2004).

While there are likely multiple explanations for this finding, it

is likely that many first responders have a working coping style,

often including some element of avoidance, that is successful.

By forcing these individuals to repeatedly relive the trauma and

face the accompanying emotional turmoil, successful adapta-

tion may be prevented. Research on CISD suggests that pro-

viding psychological treatment to all who experience a trau-

matic event may actually harm those receiving it. Wakefield

(2011) notes that similar to PTSD, the meaning of bereave-

ment’s depressive symptoms depend on the context in which

they occur. Re-defining bereaved individuals as ill subject them

to unwanted treatment that may challenge pre-existing coping

skills.

However, if a medication can reduce symptoms and improve

functioning, should everyone losing a loved one be required to

simply “muddle through” (Horwitz & Wakefield, 2007: p. 23)

life’s inherent complications when there is a relatively conve-

nient pharmacological alternative? Aside from the possible side

effects of antidepressants and the finding that 30% - 40% of

patients prescribed these medications fail to improve, is there

potential harm from labeling all recently bereaved individuals

as psychiatric patients? As a clinician, the author remembers

the days before SSRIs when tricyclic antidepressants (TCAs)

were commonly prescribed. While SSRI’s are not free of side

effects, they are not usually as disruptive as the pronounced

sedation, and anticholinergic effects during the first 7 - 10 day s

of taking a TCA. The question remains—if there are few ad-

verse medication effects and the patient appreciates the possi-

bility of being a non-responder, is there any reason not to be

treated for bereavement?

If grief is seen as having little value and as an unfortunate

life event that temporarily impairs functioning, the availability

of pharmacotherapy to aid in coping should be welcome. Simi-

lar to cognitive enhancement with drugs such as Modafanil

which extend concentration, antidepressant medication can re-

duce some of the distress accompanying bereavement. Critics

of psychiatric enhancement are often described as espousing

“pharmacological Calvinism” (Klerman, 1972), a view that dif-

ficulties in cognitive-emotional functioning are meaningful,

character-building burdens to be shouldered rather than atte-

nuated with psychotropic medication. Calvinism in particular,

is relevant when it comes to bereavement. Medication may

“cheapen” the experience of grief by making it less intense and

disruptive to one’s life. In some cultures, an individual demon-

strating little sadness after the loss of a parent or spouse would

be considered deviant because of the absence of extended

mourning. Contemporary mental health Calvinists, argue that it

is immoral to feel “good” after the loss of a loved one. Indeed,

even in industrialized countries such as the US, there is concern

that getting back to “normal “ too soon is a form of denial and

will be associated with a high level of unresolved grief or de-

layed emotional upheaval.

Conclusion

This essay has reviewed the clinical, empirical, and philoso-

phical issues raised by both proponents and opponents of the

DSM-5 bereavement exclusion. Whether widespread clinical

application of DSM-5’s bereavement exclusion will increase

the incidence of MDE diagnoses remains to be seen. In addition,

how readily patients will seek and accept pharmacotherapy to

address the grief of interpersonal loss is also an open question.

The “ground work” for pharmacotherapy of bereavement has

been laid with the use of SSRIs to “buff up” one’s personality

(Kramer, 1993), and drugs such as modafanil to improve cogni-

tive functioning a nd eliminate fatigue associ ated with shift work.

However, bereavement, with its often specific cultural and reli-

gious context, does not appear comparable to these other uses

of enhancement therapy. The ethical issues surrou nding “ar tifici al”

coping with loss through the medicalization of bereavement are

likely to continue to be debated.

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