Wednesday, February 17, 2010

Commentary - DSM5 Criteria Won’t “Medicalize” Grief, if Clinicians Understand Grief

An interesting commentary on the revisions to the DSM, from Psychiatric Times. I'm glad to see that some psychiatrists are opposing the medicalization of ALL psychological suffering.

Equating situational bereavement - grief - with major depression is just another way to create a market for [ineffective] antidepressant medications. NO ONE with connections to the pharmaceutical companies should sit on the DSM panels.

DSM5 Criteria Won’t “Medicalize” Grief, if Clinicians Understand Grief

By Ronald Pies, MD, and Sidney Zisook, MD

Sidney Zisook, MD, is professor of psychiatry and director of residency training at the University of California, San Diego. Ronald Pies, MD, is professor of psychiatry at SUNY Upstate Medical University; clinical professor of Psychiatry at Tufts University School of Medicine; and Editor-in-Chief of Psychiatric Times. | February 16, 2010

“The exclusion of symptoms judged better accounted for by Bereavement is removed because evidence does not support separation [or] loss of loved one from other stressors.”1

With this simple rationale, the framers of DSM5 would, according to Dr Allen Frances, “…reverse 30 years of diagnostic practice and allow the diagnosis of Major Depression to be made for individuals whose grief reaction symptomatically resembles a Major Depressive episode.”2

We respect Dr Frances’s numerous attempts to improve the DSM5 process and acknowledge that he has raised important questions about several proposed DSM5 diagnoses.2 However, we support the proposal to eliminate the bereavement exclusion from the criteria for Major Depressive Episode (MDE) and disagree that this amounts to “medicalizing normal grief.”2 Indeed, we believe it begs the question—that is, assumes as true precisely what is in dispute—to suggest that someone who meets full symptom and duration criteria for MDE after a major loss merely “resembles” someone with a MDE. Nor do we believe that “grief reaction” is necessarily the right term for someone who meets full symptom and duration criteria for MDE, but who happens to present within two months of a major loss, including but not limited to the death of a loved one.

And, while we take Dr Frances’s point that “…grief would become an extremely inviting target for the drug companies”2, we believe that DSM5 criteria sets should be based on the best available science, not on predications regarding the behavior of pharmaceutical companies. Furthermore, by eliminating the bereavement exclusion, the DSM5 would bring its criteria for MDE in line with those of the International Classification of Disease, 10th edition (ICD-10). In the ICD-10, if Mr Jones meets criteria for a depressive episode-- notwithstanding the recent death of his wife-- he gets the diagnosis of depressive episode, subtyped as mild, moderate, or severe.4 We fully expect that this paradigm will continue in the ICD-11, now anticipated in 2014. Harmonizing the DSM and ICD criteria is consistent with a goal advocated by Dr Frances himself.3

So what, in our view, does the best available science show? While acknowledging that definitive studies have yet to be done, we believe the best studies to date 4-6 lead to the following conclusions:

1. There are no convincing data that show depression in the context of loss to be fundamentally different than any other kind of depression, when full DSM symptom and duration MDD criteria are met.
2. In contrast, there is evidence demonstrating that Bereavement-Related Depression (BRD) is similar to other instances of depression occurring in the context of other major losses (job loss, divorce, etc.) in terms of risk factors, severity, associated features, patterns of co-morbidity, biology, course and treatment response.
3. The current (DSM-IV) differentiating features for bereavement are not predictive of lower depression severity or risk.
4. There are no convincing data showing that the bereavement exclusion for the diagnosis of major depression protects against “pathologizing” normal grief, or against over-diagnosing major depression.
5. In contrast, it is not unlikely that the bereavement exclusion may lead, paradoxically, to keeping some severely depressed individuals who happen to be bereaved, or whose depressive episode was precipitated by death of a love one, from receiving much- needed treatment.

As we stated previously, we believe “…that continuing the bereavement exclusion in DSM5 would be a serious error. It would encourage bereaved individuals, their families, and health care providers to ignore signs and symptoms of a potentially debilitating, life-threatening, yet treatable disorder. Extending this exclusion to still other loss events could create a public health disaster.” 7

We share Dr Frances’s concern that “false positives” may occur when clinicians apply the proposed DSM5 criteria for MDE, but not because the bereavement exclusion has been eliminated (though presumably, that change will increase the total number of diagnosed MDE cases). Rather, we believe “false positives” are more likely when a patient presents with only 1-2 weeks of MDE symptoms—whether or not they are in the context of a recent loss. Although the required epidemiological studies have not been done, we believe that a 3-4 week minimum duration criterion for MDE symptoms would probably cut down on the number of such false positives, since many shorter-duration syndromes (1-2 weeks) often resolve spontaneously. This is especially true, in our experience, when the depressive symptoms are relatively mild in intensity; and perhaps also when the symptoms are temporally associated with a transient or reversible stressor.

Finally, with respect to both DSM4 and the draft of DSM5, we believe too little attention has been paid to the phenomenological features that distinguish “normal” grief and bereavement from psychopathological states, such as complicated grief or major depressive disorder. By “phenomenological”, we mean aspects of the patient’s subjective experience or sense of self. 8-10

For example, in ordinary or “productive” grief8 and bereavement, the individual typically maintains her emotional connection with others; believes that the grief will end some day; maintains her self-esteem; and experiences positive feelings and memories along with painful ones. Guilt, if present, is focused on “letting down” the deceased person, rather than on being “worthless” or useless. In ordinary grief, loss of pleasure is related to longing for the deceased loved one, as opposed to the pervasive anhedonia often seen in severe depressions; and suicidal feelings are more related to longing for reunion with the deceased than to thoughts of not deserving to live. Moreover, as Dr Kay R. Jamison has noted, in ordinary grief, an individual is capable of being “consoled” by friends, family, music, literature, etc.11

In contrast to all this, in severe depression—particularly in the melancholic subtype—the individual tends to be extremely “self-focused”; feels outcast or alienated from friends and loved ones; has the sense that the depression will “never end”; experiences profound self-loathing and guilt; experiences few if any positive feelings or memories; and is often “inconsolable.” 8-11
We acknowledge that careful empirical investigation is required to confirm these largely observational findings; but we believe that the DSM5 text should include such phenomenological descriptors, even if the official criteria sets do not. In the mean time, we urge further investigation into both the biology and phenomenology of uncomplicated grief, complicated (pathological) grief, and MDD. 8

In conclusion, we do not believe that elimination of the bereavement exclusion by itself will lead to the “medicalization” of grief; rather, we believe it will encourage those with potentially serious depressive illness, after recent loss, to seek help. Nor do we believe that elimination of the bereavement exclusion by itself will lead to over-medication, so long as clinicians are trained to apply DSM-5 criteria for MDE; to avoid premature prescription of antidepressants (eg, within the first week of depression); and to consider psychotherapy as the first-line treatment for short-lived, mild-to-moderate depression. To be sure, all this will require stepped-up training of both psychiatric and (especially) primary care physicians.

Finally, we believe it is time for the DSM to look more carefully at phenomenology—the contents of the patient’s felt experience—rather than relying almost entirely on behavioral and symptomatic check-lists.

2.Frances A: Opening Pandora’s Box: The 19 Worst Suggestions For DSM5.
3.Frances A: A Warning Sign on the Road to DSM-V
4.Zisook S, Kendler KS: Is bereavement-related depression different than non-bereavement-related depression. Psychological Medicine: 1-31, 2007
5. Zisook S, Shear K, Kendler K. Validity of the bereavement exclusion criterion for the diagnosis of major depressive episode. World Psychiatry. 2007 June; 6(2): 102–107. Accessed at:
6. Corruble E, Chouinard VA, Letierce A, et al. Is DSM-IV bereavement exclusion for major depressive episode relevant to severity and pattern of symptoms? A case-control, cross-sectional study. J Clin Psychiatry. 2009 Aug;70(8):1091-7.
7. Zisook S, Pies R. Letter, Psychiatric Times (response to Wakefield and Horwitz)
8. Pies R. The anatomy of sorrow: a spiritual, phenomenological, and neurological perspective. Philos Ethics Humanit Med. 2008; 3: 17. Accessed at:
9. Ghaemi SN. Feeling and time: the phenomenology of mood disorders, depressive realism, and existential psychotherapy. Schizophr Bull. 2007;33:122–30. 10. Zisook S, Shear K. Grief and bereavement: what psychiatrists need to know. World Psychiatry. 2009 June; 8(2): 67–74. Accessed at:
11.Jamison KR. Nothing Was the Same. New York, Knopf, 2009.


Ronald Pies MD said...

Hello, and thanks for giving a "shout-out" to the commentary by Dr. Zisook and me.

Dr. Zisook and I would agree with you that equating situational bereavement or grief with major depression is a mistake. We would also counsel against use of medication for "ordinary" grief that does not meet full criteria for major depression (some cases do, most do not).

In those cases in which all criteria for major depression are met, the use of an antidepressant may be appropriate for particularly severe cases; and there is no convincing evidence that such medication "interferes" with the grieving process.

I would respectfully disagree with your characterization of antidepressants as "ineffective." This is a view given more credence recently, owing to the unfortunate article by Sharon Begley, in Newsweek.

I hope you and your readers will keep an open mind, and take a look at the commentary I have on the Begley piece, at:

In the spirit of disclosure, I have no affiliations with any pharmaceutical companies, am not on any "speakers' bureaus" etc. I am Editor in Chief of Psychiatric Times, and a full disclosure statement may be found on the website psychiatrictimes. com, by clicking on "Board".

Thanks for the opportunity to reply.

Ronald Pies MD

william harryman said...

Dr. Pies,

Thank you so much for sharing your thoughts here - I appreciate your comments!

As a counseling student, I tend to be concerned about what seems like the over-medicalization of mental health. I understand the drive toward an evidence-based model, but I also tend to think that reducing all subjective states to physical/material processes is dangerous.

My blanket statement that antidepressants are ineffective was unfair - in many instances they are effective, and even when they may only offer "placebo effect" relief, they do spur hippocampal neurogenesis, which may be the real benefit in treating depression.

I also am aware of the studies showing personality trait revision in response to SSRIs, as noted by Joan Arehart-Treichel at Psychiatric News (

I will post your response to the Begley article as a separate entry here so that readers can get a more balanced awareness (since I had posted the Begley article here earlier).


Anonymous said...

Thanks, Bill, for the temperate response (all too rare these days!).

I actually believe that many, if not most, psychiatrists would agree with you that "over-medicalizing" mental health issues is a real danger to the field; on the other hand, so is what I call the "forced normalization" of psychopathology, as when a major depression is "normalized" as a kind of glorified bad-hair day!

As for "reducing all subjective states to physical/material processes"--well, from a philosophical standpoint, that is a gigantic kettle of worms! Part of the problem lies in the pejorative connotation of the word
"reducing"--quite different than when we say, for example, that molecular biology may be "reduced" to biophysics. I strongly recommend reading Owen Flanagan's fine book, The Problem of the Soul.

That said: in everyday, clinical matters, I completely agree that our conversations and approaches to patients must not be purely based on a "biological" model. I try to articulate this in my article in PEHM, on "The Anatomy of Sorrow." My approach is pluralistic, as I think you will find.

I appreciate your clarification of the role of antidepressants, as well--overused, yes, but also greatly under-used when they could be life-saving.

Best regards,
Ron Pies

william harryman said...

I have downloaded the article you wrote on grief and depression - looking forward to reading it.

And I will get Flanagan's book - consciousness studies is a hobby that informs my education in therapy, so his book will add to the material I have been reading (constructivism, pragmatism, Jerome Bruner, Searle, Edelman, Cultural Psychology, and many others).