Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Sunday, May 5, 2013


Bereavement was the winner-the DSM-5 change that those who took my survey believe has the potential to do the most harm.

This feels especially relevant to me, since I lost a parent a couple months ago. (Life goes on, gotta keep blogging through).

To review, in DSM-4, Bereavement gets a V-code (other conditions that may be a focus of clinical attention): V62.82:

This category can be used when the focus of clinical attention is a reaction to the death of a loved one. As part of their reaction to the loss, some grieving individuals present with symptoms characteristic of a Major Depressive Episode (e.g., feelings of sadness and associated symptoms such as insomnia, poor appetite, and weight loss). The bereaved individual typically regards the depressed mood as "normal", although the person may seek professional help for relief of associated symptoms such as insomnia or anorexia. The duration and expression of "normal" bereavement vary considerably among different cultural groups The diagnosis of Major Depressive Disorder is generally not given unless the symptoms are still present 2 months after the loss. However, the presence of certain symptoms that are not characteristic of a "normal" grief reaction may be helpful in differentiating bereavement from a Major Depressive Episode. these include 1) guilt about things other than actions taken or not taken by the survivor at the time of death; 2) thoughts of death other than the survivor feeling that he or she would be better off dead or should have died with the deceased person; 3) morbid preoccupation with worthlessness; 4) marked psychomotor retardation; 5) prolonged and marked functional impairment; and 6) hallucinatory experiences other than thinking that he or she hears the voice of, or transiently sees the image of, the deceased person. (DSM-4 TR Desk Reference, Pp. 311-12).

And don't forget, in the DSM-4 definition of a Major Depressive Episode (ibid. p. 169), criterion E specifies that the symptoms are not better accounted for by Bereavement:

I.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked funcional impairment, ... worthlessness, suicidal ideation, psycho(sis), or psychomotor retardation. 

So, same as above.

Considering this in light of the imminent publication of DSM-5 (incidentally, I thought it would be published on the 3rd, but Amazon doesn't have it til the 27th, B&N the 22nd ), it doesn't seem like that much of an improvement.  Two months is not a very long time following a loss. And functional impairment and psychomotor retardation sound like the kinds of things that might linger for a while.

While I'm trying to make the argument that even DSM-4 pathologized grief, I think I'm only succeeding in making the argument that grief, or bereavement, may be hard to differentiate from Major Depression. And this, I believe, is the force behind the removal of the exclusion criterion.

Reading up on this topic just made me more confused than I already was. So I'll try to stick to my basic questions, and share with you what I've learned so far.

1. How can I tell if my patient is depressed, or simply grieving following a loss?
2. How important is the time factor, (i.e. 2 months)?

Since the road to understanding should be paved with clarity, I think we need some working definitions. These are from:

Zisook, S; Shear, K; Grief and bereavement: what psychiatrists need to know; World Psychiatry. 2009 June; 8(2): 67–74.

Bereavement is the actual loss-the death of a loved one. Grief is the emotional reaction to the death. And mourning describes some of the typical behaviors associated with the death, like funerals or religious practices.

The same paper also differentiated between Uncomplicated Grief, Complicated Grief, and Grief-Related Major Depression.

For me, these are useful concepts, because they point to the difference between what is and isn't expectable following a bereavement. You can read the specifics in the paper, but the idea is that, in uncomplicated grief, there is an intense, acute phase, followed by a resolution into a less intense phase, "integrated grief". In complicated grief, seen in 10% of grieving individuals, the transition to an integrated state never occurs. And grief-related major depression is neither uncomplicated nor complicated grief. It is a major depressive episode that occurs following a bereavement.

Now the question is, if a patient meets criteria for a major depressive episode within 2 months of a death, is this really grief disguised as depression, is it depression in addition to grief, or is it depression brought on by the loss that caused the grief, or by the grief, itself?

According to the Zisook paper, between 24% and 42% of recently bereaved subjects met criteria for a major depressive episode within the first 2 months following a bereavement. And 16% were still depressed at 12 or 13 months (depending on the study). Most importantly, the best predictor for depression at 13 months was depression at 1 or 2 months. A past history of major depression also predicted depression at 1 year following bereavement. And bereaved persons are also at risk for lingering subsyndromal depressive symptoms. In addition, bereavement, itself, can precipitate a depressive episode.

This paper, along with others by the same author(s) concludes that bereavement related depression is similar to non-bereavement related depression, which implies the removal of the bereavement exclusion is valid: If it looks like depression, then it IS depression, and should be treated as such.

Well, maybe.

Another paper,
Mojtabai, R; Bereavement-Related Depressive Episodes Characteristics, 3-Year Course, and Implications for the DSM-5Arch Gen Psychiatry. 2011;68(9):920-928, has a different take. I found this paper clearer and more convincing than the previous one, although this may not be evident from my description (read 'em!).

This study looked at a very large sample and compared the characteristics and outcomes of 5 different groups: 1. Those with a single, brief (<2 months) episode of depression following a bereavement; 2. Those with a single, brief episode of depression not following a bereavement;
3. Those with a single, non-brief (> 2 months) episode; 4. Those with recurrent depressive episodes; and 5. Those with no lifetime history of depression.

In terms of baseline characteristics, group 1 (single brief episode following bereavement) was more likely than group 2 to be 50 or older and to be non-Hispanic Black. Group 1 was less likely than group 2 to have impairment in functioning, to have onset in their 20's, to have a co-morbid anxiety disorder, to have sought treatment, or to have been prescribed medication for depression.

Compared with group 4, group 1 was less likely to have a family history of depression, comorbid alcohol dependence, and onset before the age of 20 years.

In terms of symptom profiles, group 1 was less likely than group 2 to experience feelings of worthlessness, suicidal ideations, increased sleep, or fatigue.

And as far as follow up goes, "Participants with bereavement-related, single, brief depressive episodes were not more likely than participants without a lifetime history of depression at baseline to experience a depressive episode during the 3-year follow-up... However, participants with bereavement-unrelated, single, brief depressive episodes had an elevated risk of experiencing a depressive episode at follow-up compared with participants without a history of depression..., and compared with those with bereavement-related depressive episodes (14.7% vs 8.2%, adjusted odds ratio [AOR], 1.88; 95% CI, 1.05-3.38; P = .04). Participants with single, nonbrief depressive episodes also had an increased risk of new depressive episodes in follow-up compared with participants with bereavement-related, single, brief depressive episodes..., as did participants with recurrent depressive episodes compared with those with bereavement-related, single, brief depressive episodes..."

There's a whole lot more, obviously, but to summarize what I've learned so far:

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.
I am now more educated and less certain about this topic than I was when I started to research it. One question I haven't really taken up is, why 2 months? Why not 2 weeks, if we're talking about criteria for major depression? Or longer than 2 months? 

What will be the effect of the removal of the bereavement exclusion? Will fewer treatable depressions be missed? Will morbidity increase from treating conditions that don't require treatment, or from pathologizing normal processes?
The answer is the same as the solution to grief, itself. To quote Viola from Twelfth Night:

O time! thou must untangle this, not I;
It is too hard a knot for me to untie!



  1. My head hurts.

    People who are grieving turn to friends, family, clergy, not psychiatrists.

    The older I get, the more I realize that none of this really matters. If a grieving patient shows up, try to say comforting things. Probably best not to suggest their distress is because they are mentally ill. If they insist they want to see if a drug will help ease their agony, I tell them they don't make pills for this, and I then I prescribe a low dose anyway. If they are in agony but aren't asking for medicine, I might offer it. If they say they want it, fine, if they say no, I respect that too. What exactly do we get from shoving people's reactions into diagnostic boxes? Oh yes, insurance reimbursement.
    Screw DSM and treat the patient and respect that different patients have different responses and different wishes.
    I'll send you a bill

  2. Bereavement Exclusion in Major Depression

    As had previously been announced, DSM-5 drops the so-called "bereavement exclusion" from the diagnosis of major depressive disorder, under which the diagnosis was forbidden in individuals suffering a recent death of a loved one. Critics charged that the change would prompt many people experiencing "normal grief" to be labeled as depressed and given antidepressants, to the benefit of drug companies.

    Kupfer said the criticism had arisen from "a misperception of what we were seeking to do and have done." He noted that patients in the grieving process are not immune from genuine, unhealthy depression. The task force's goal in dropping the exclusion was to "prevent major depression from being overlooked in some individuals who may be undergoing some form of grief or bereavement."

    An APA fact sheet distributed at the briefing pointed to several features that "usually" distinguish depressive illness from normal grief in patients experiencing recent losses. They include continuous unrelieved negative mood and feelings of worthlessness and self-loathing. In normal grief, extreme sadness is typically intermittent and self-esteem is unaffected, the fact sheet said.

    Dr Katherine Shear, the director of the Center For Complicated Grief has developed a focused 16 week therapy for those suffering from Complicated Grief.

    Check out this article about complicated grief, " A New Treatment Program for the Grief That Won't End"

  3. If grief is severely impairing ones ability to function in key roles or if a person is having persistent suicidal thoughts, it is essential to seek professional help from someone trained in the treatment of loss to decide whether medication -- along with therapy -- might be helpful. Dr Katherine Shear, the director of the Center For Complicated Grief at Columbia University School of Social Work has developed a focused 16 week therapy, complicated grief therapy that has been proven efficacious in clinical trial to help those with complicated grief. People with Complicated Grief often say that they feel "stuck", grief dominates their lives with no respite in sight. Dr Shear's 16 week treatment guides people in resolving grief complications and revitalizes the natural healing process.