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June 19, 2013

Bereavement and Major Depressive Disorder

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Alan J. Gelenberg, MD

Penn State University, Hershey, Pennsylvania

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The DSM-5 dropped the bereavement exclusion from the diagnosis of Major Depressive Disorder. In the DSM-IV, this exclusion meant that people grieving the loss of a loved one could not be diagnosed with MDD until 2 months after the death. In an essay in The Lancet, Dr. Arthur Kleinman pointed out that the DSM-III had a 1-year bereavement exclusion, and he called the 2-month limit on normal grief “shockingly short.” While acknowledging that setting a time frame for normal grief to end is problematic, he also questioned whether the absence of the bereavement exclusion could lead to “medicalizing” normal grief.

By leaving out the bereavement exclusion, the DSM-5 relies on physicians to distinguish grief from depression at any time point following a person’s loss. Concerning this distinction, Freud’s elegant monograph Mourning and Melancholia bears re-reading today. Freud described grieving as a gradual, healing process of saying good-bye and moving forward with the rest of one’s life.

The thought of turning natural grief into an illness and treating it with drugs is anathema to me. Grieving truly is a normal, personal, intimate process.

But sometimes loss can trigger the pathological mood state of depression. I have seen patients whose normal grief went off track and ground to a halt when the pall of depression descended on them. Treatment with antidepressants or psychotherapy helped them to resume the healing process, move forward in their grieving, and find their place again in the world.

As clinical psychiatrists, we must recognize the difference between grief and depression. We should not medicalize a normal process, but we need to acknowledge when a grieving person has developed MDD and legitimately needs treatment.

Financial disclosure:Dr Gelenberg is a consultant for Zynx, has received grant/research support from Pfizer, and is a stock shareholder in Healthcare Technology Systems. His own blog can be found at http://www.btpnews.com/blog.

Category: Depression
Link to this post: https://www.psychiatrist.com/blog/bereavement-and-major-depressive-disorder/
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23 thoughts on “Bereavement and Major Depressive Disorder

  1. There is a nice CME article in ?January/February issue of the Archives. I think the DSM creators are helping the practicing Psychiatrists to lose faith in DSM’s diagnostic tree, criteria etc.
  2. Who is best served when this exclusion is left out? Is it the patient who is encountering a potentially rich and productive period of growth or the physician who finds that sitting with another’s grief triggers in them discomfort that they would prefer to avoid?
  3. This post (written by yours truly): http://psychpracticemd.blogspot.com/2013/05/bereavement.html
    looks at some of the literature that addresses the removal of the bereavement exclusion, and what to do if you have a recently-bereaved patient with symptoms of depression.

    Here’s the summary:

    Post-bereavement, it’s appropriate to assess the grieving patient for depression, in addition to, or as a result of, or instead of, grief. Within the first 2 months, if the patient does not have 5 of the 9 criteria for a major depressive episode, then the patient is not experiencing a major depressive episode, and is assumed to be grieving.

    What if the patient does have 5 of the 9 criteria? It depends who you ask:

    *According to DSM-4, if less than 2 months have passed since the death, AND there is no evidence of marked funcional impairment, … worthlessness, suicidal ideation, psycho(sis), or psychomotor retardation, then the patient is not depressed, but rather grieving. But if more than 2 months have passed, OR any of these symptoms is present, regardless of the time frame, then the patient is depressed.
    *According to DSM-5, the patient is depressed.
    *According to the Zisook paper, the patient should probably be treated for depression, since post-bereavement depression is similar to bereavement unrelated depression.
    *According to the Mojtabai paper, the patient is likely to fare better than one with a bereavement-unrelated depression, with fewer sequelae and less severity, and this should be factored into the decision to treat.

  4. Interesting this position of DSM V. Finnally, we look at the behavior during grief triyng to understand it and recognize the existence, or not of really depression. I agree with Freud.as I did in 2000, when I wrote ”Loss and grief during bereavement”- a descriptive study about feelings and bereavement process in elderly women and elderly widows after conjugal loss. This work has been orientated by Prof Caldas de Almeida, to be presented in Master of Gerontology of the University of Salamanca. Mª da Luz Larangeira- from Portugal
  5. I thank Dr. Gelenberg for his comments on this very controversial issue. I believe he is precisely right when he states,

    “…we must recognize the difference between grief and depression. We should not medicalize a normal process, but we need to acknowledge when a grieving person has developed MDD and legitimately needs treatment.”

    Indeed, the death of a loved one–far from “excluding” a bout of major depression–is a common precipitant of MDD. Moreover, there are substantial differences between ordinary, “productive” grief and major depression. The DSM-5 does a reasonably good job of discussing these differences in the now famous “footnote” on p. 161 of the text. I would urge all clinicians to read this over before reaching a judgment on the DSM-5’s decision to eliminate the bereavement exclusion. For more on this issue, I hope readers will also see the article link below:

    http://psychcentral.com/blog/archives/2013/05/31/how-the-dsm-5-got-grief-bereavement-right/

    No, we should not “medicalize” grief; but neither should we normalize major depression merely because it emerges in the context of a recent death.

    Best regards,
    Ron Pies MD

  6. Thanks, Dr. Aliyev, for your cordial comments.

    Indeed, I do trust that psychiatrists can tell the difference between ordinary grief and major depression. Of course, most people with depression–if they get treatment at all in the U.S.–first see a primary care physician. I am aware of the argument that says, “The PCP is too rushed to make a considered and accurate diagnosis.” But I think this sells our non- psychiatrist colleagues short. I think that with the right kind of consultation and continuing medical education, psychiatrists and PCPs can work collaboratively to refine the diagnosis of patients presenting with grief, depression, or both.

    But this won’t happen without concerted time and effort!

    Regards,
    Ron Pies MD

  7. Whatever one thinks of Freud’s works now. He must be given credit for astute observations and some truly brilliant theories of the ‘mind’. Which to this day, none of can say we truly understand. I’ve read his works. I finished training in 1994, the Decade of the Brain, and was heavily into Neuroscience. Ten years later I had achance to interact with incoming 1st yr residents. They were all very research oriented, but knew nothing at all about ego mechanics. I was dumbfounded. I told them the the ego defenses were defined in the first chapter of the require text book. My point is this yes I agree, an astute psychiatrist should be able to tell when their patient has descended from normal grief into MDD. Or as is often the case in persons with bipolar disorder, mania. My problem with the DSM V and the way that mental health care is currently being delivered in the US is that the vast proportion of these patients will never be seen by a psychiatrist (except the manic one, perhaps). They are being treated in 10-15 min visits with there PCP doctors, of various training backgrounds and all pressed for time. They see a low dose of an SSRI as harmless as a baby aspirin, a day. Psychiatrists know that is not the case. this is a problem. Personally, there is still stigma. My father, for instance, we all know, and he admits that he has bipolar disorder. He is 75yo now on Paxil from his internist which he can’t get off of, and has very unmanageable irritability. He has refused to see a psychiatrist for ten years, even though his daughter is one. I do not think my father is alone in his stubborness. As psychiatrists, I feel that we must reach out and form alliances with our PCP colleages. Many practices in my area are set up with both. That is the ideal for both patients and physicians.
  8. I agree, Dr. Bell, with the proviso that when “talk therapy” alone can do the job–and the patient has affordable access to it–I prefer to begin with that modality, usually for mild-to-moderate depressive symptoms. But I agree with the core principle you are articulating; i.e., looking at functional capacity (and degree of suffering) rather than getting too fixated on a diagnostic “box”.

    Regards,
    Ron Pies MD

  9. I certainly wont like to medicalise human right and ability to grieve, but what when the individual experiences symptoms of anxiety that cannot endure and asks for help? Then at least a short term therapy could be justified.
  10. Good points in this article. Judgement is paramount as not all people are through grief in 2 months. I get that was the consensus, however it took me quite a few years to get through the loss of my son, brother, father, 2 best friends, and many other friends all within a 2 year time frame. I was more in shock. Loss is related to what the person meant to you, and I would be concerned about pathologizing normal grief that last longer than 2 months and is not depression. Lots of great comments here.
  11. It appears that there is an eagerness to medicalize every human normal emotional situation and and give pills. This is a modern phenomena as western cultures have lost the rituals in case of death in a family and the grief process and also support to the person who had a loss. Therefore In my opinion it is important to learn from other cultures where rituals are still in place and how they go through normal grief process, instead of medicalizing and giving pills. Of course in certain individuals should major depression is precipitated by a loss then treatment should be tailored appropriately.
  12. When Bruce Lee was asked what his method of martial arts was to be called, he said thatnhis method was “no method but being like water, changing its shape according to the nature of the circumstances one faces.” Two troubling words are coming out of the discourses above:1-Medicalize and 2-Procrustean.Medicalize, when seen with the adjective Hippocratic changes the world view of a healer with a Shakespearean breadth of interest in allthings human and eliminates the ugly result from the ugly words”cold and clinical” which results in “Procrustean” which means that one lops off the parts of our patients’ bodies and souls that do not conform to our fascistic notion of what the world should be the way we order it to be as in Dag Hammarskjold’s quote:”If you see yourself as a hammer,you will see all problems as nails.”Truce T. Ordona,M.D.,FMCH,Iowa
  13. Our society has very low tolerance for behaviors that are anything but cheerful and pleasant. Grief is one of those. Intrusive attention-seeking is another. Anger is a third. Anxiety is a fourth. All are well within the normal range of human behaviors, but because we CAN change them with medications, we assume that they are illnesses! I can reduce your anxiety in the pre-surgery suite with Benzodiazepines, but does that mean that pre-surgical anxiety is a disease? Anyone not worried about being cut open in the age of MERSA might be considered a hysteric!
    Let’s work on increasing society’s tolerance for “uncomfortable behaviors” instead. Use compassion, presence, patience and kindness rather than pills.
  14. I think a careful reading of the DSM-5 will reassure many who see the new classification as an attempt to “medicalize every human, normal emotional situation.” I think the DSM-5 makes conscientious efforts to distinguish pathological states from ordinary emotional reactions.

    For example, on p. 168, the text states
    “…periods of sadness are inherent aspects of the human experience. These periods should not be diagnosed as a major depressive episode unless criteria are met for severity…duration… and clinically significant distress or impairment.”

    Also, on p. 716, “Uncomplicated bereavement” is listed as a “V” code–not as a mental disorder–and is described as a “normal reaction to the death of a loved one.” Descriptive features are also provided.

    Of course, clinicians will need education and training to make these distinctions–and cannot possibly do so in a 12 minute meeting with the patient! But these are problems of education and health care delivery–not problems that can be solved in a diagnostic manual.

    Ron Pies MD

  15. Grief is a normal process in our life as is death or birth. We should not try to ‘categorize’ everything in life as abnormal just because we want to avoid it and ‘medicate’ our way out of it. It took me a good two years to wander my way through the sadness of the passing of my parents. When all has been said and done it is a rich experience that I have been able to draw from in assisting my own patients in dealing with their grief
  16. Of course, nobody disputes the idea that grief is a normal process. The question is, what about the grieving person who, at the same time, meets all symptom, severity and duration criteria for a major depressive episode? This is not the usual picture in uncomplicated grief.

    These individuals may indeed need some professional care and treatment.

    Ronald Pies MD

  17. Very often, when a patient in the department behaves in a way that is different from his usual, the staff comes to me with his medication sheet. I usually ask the nurse what would he/she do in the specific patient’s circumstances, and very often prescribe ” a pat on the shoulder, stroking patient’s head and adding a soft smile”. It very often works and denies the need for medication, additional or incresed.
  18. Dr Gelenberg’s comment summarizes our concerns very succinctly. The course of mourning and the mental operations are exceedingly complex.Long term consequences such as anniversary reactions,profound effects of sibling death,and loss during war and terror amplify Freud’s insight of the way in which ambiguity,ambivalence,and psychological conflict inhibit and distort the normative existential process of adapting to loss. Psychotherapy and pharmacotherapy can be helpful to stabilize domains of dysregulation[mood,anxiety] and restore perspective
  19. I have a patient whose Norwegian husband died several years ago from Frontotemporal Dementia.
    Since then this lady has spoken with something appoximating a Norwegian Accent ( So called Foreign Language Speech Disorder) . On the one hand one could take a psychodynamic view and say that she taking on to preserve some aspect of the loved object. On the other hand I find myself wondering if there has been a dysfunction affecting Brocas Area (perhaps reduction in grey matter volume ).
    I wondered what people think about this. She hasnt responded to Neuropsychiatric or Psychotherapy Interventions
  20. I think the APAs explanation is reasonable. Experts working in the field of bereavement believe that the depression can go on for a much longer time than 2 months, in fact it can, for a year or 2 in many cases. So there are two options: do away with the 2 months’ clause, or extend the cut off point to say 1 year. The DSM-5 chose the former option.

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