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Treatment Outcome for Bereavement-Excluded Depression: Results of the Study by Corruble et al Are Not What They Seem

To the Editor: In their recent article,1 Corruble and colleagues claim that individuals excluded from major depressive disorder (MDD) diagnosis by the DSM Criterion E bereavement exclusion (BE) had treatment outcomes no better than other MDD patients: “[O]ur results show that the 6-week outcome of depressed patients with versus without the MDE [major depressive episode] Criterion E bereavement exclusion is not different.”1(p5) They conclude that the BE is invalid and join those who “argue against the continued use of the bereavement exclusion criterion in DSM-5.”1(p5)

The authors’ conclusions do not follow from their data. Their results show nothing about BE-excluded individuals’ outcomes, because the sample generally did not qualify for exclusion. The BE does not allow exclusion if any 1 of 6 problematic conditions is present—either duration over 2 months or suicidal ideation or psychomotor retardation or morbid worthlessness, etc (see below). Table 3 in the authors’ article reports the “BE” group’s baseline symptoms: 70.5% psychomotor retardation, 66.8% worthlessness, and 36.0% suicidal ideation. Yet any one of these symptoms disqualifies an individual from BE exclusion. Consequently, the sample generally qualified for MDD.

How can this be? Corruble et al analyzed responses of French general physicians (74%) and psychiatrists (26%) to a questionnaire regarding their depressed patients.2 The individuals the authors classified as BE-excluded were those for whom the clinicians indicated “no” to criterion E (the BE). Corruble et al accepted clinicians’ judgments at face value, not examining whether the clinicians applied the BE correctly. The fact that the “excluded” group reported symptoms that prevent exclusion indicates that the clinicians did not apply the criterion correctly. Clayton3 identified this problem in an earlier article, yet nowhere is this severe limitation that negates the authors’ claims mentioned.

To understand the clinicians’ errors, recall how the BE is stated in DSM-IV:

The symptoms are not better accounted for by Bereavement, ie, after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.4(p327)

Criterion E is described as the “bereavement exclusion,” but in fact is worded as an MDD inclusion criterion. Consequently, even the common statement that an individual “satisfies the bereavement exclusion” is ambiguous—it could mean either that the individual fulfills criterion E (ie, does not have excludable bereavement, thus has MDD) or that the individual has excludable bereavement and does not qualify for MDD. To apply the BE, one must evaluate a confusing double negative. Indeed, one of us (M.B.F.) encounters the resulting confusion frequently when doing Structured Clinical Interview for DSM-IV (SCID) training sessions, with novice SCID users often coding criterion E oppositely to what they intend. The most plausible hypothesis to explain the discrepancy between the supposed BE-excluded group’s symptom profile and the BE criteria is that the physicians in the Corruble et al study1 were similarly confused.

The crucial point is that these results are not generalizable to any sample or population to which the DSM BE is correctly applied. Thus, the results have no implications for the ongoing debate about the BE’s validity. At most, they indicate that the BE’s current wording is confusing to novices and requires clarification.

References

1. Corruble E., Falissard B., Gorwood P. Is DSM-IV bereavement exclusion for major depression relevant to treatment response? a case-control, prospective study. J Clin Psychiatry. 2011;72(7):898–902. PubMed doi:10.4088/JCP.09m05681blu

2. 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;70(8):1091–1097. PubMed doi:10.4088/JCP.08m04475

3. Clayton PJ. V code for bereavement. J Clin Psychiatry. 2010;71(3):359–360, author reply 360. PubMed doi:10.4088/JCP.09lr05646blu

4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association; 1994.

Jerome C. Wakefield, PhD, DSW

wakefield@nyu.edu

Michael B. First, MD

Author affiliations: Department of Psychiatry, School of Medicine and Silver School of Social Work, New York University, New York; and InSPIRES (Institute for Social and Psychiatric InitiativesResearch, Education and Services), Bellevue Hospital/New York University, New York (Dr Wakefield); Department of Psychiatry, Division of Clinical Phenomenology, Columbia University College of Physicians and Surgeons, New York, New York (Drs Wakefield and First); and New York State Psychiatric Institute, New York (Dr First). Potential conflicts of interest: The authors have no conflicts of interest to report. Funding/support: None reported.