DSM-5 in Action

Last week, I saw a new patient who was referred to me by her therapist for evaluation for med management, specifically, for depression.

The therapist wasn't certain the patient needed meds. And the patient wasn't sure she needed, or wanted meds.

She was suffering-that was the only certain thing.

I'm a decent psychopharmacologist, despite the fact that I mostly do therapy and analysis. The reason I'm good with meds is not because I'm an expert on the Cytochrome p450 system, or I'm the first shrink on the block to prescribe a brand new med. I believe it's because I listen to my patients, so important feelings/experiences/symptoms don't get overlooked, or boxed into neat little 15-minute med check categories that don't really fit.

So I listened to this patient, and while I was listening, I started thinking about everything I've learned regarding DSM-5. Like, maybe Major Depression, as defined by the DSM, doesn't really exist. (Note: I am NOT saying I don't believe depression exists. I'm just referring to the DSM definition of depression). And even if it does exist in DSM form, if I run through the checklist, and the patient meets five of the nine criteria, does that imply that she'll benefit from medication? And if she doesn't meet 5/9, does that mean she won't?

And what about the meds? What exactly am I treating? And how? A world-outlook? A traumatic childhood loss? If I can't be sure there's a disease process going on, and I can't be sure which aspect of the disease, if such it is, I'm treating, and no one even knows how the meds work, then why would I medicate?

I thought about how easy it would be to say to her, "You meet criteria for MDD, here's a pill, take it and you'll feel better." But I just couldn't bring myself to do that. I didn't believe it would help.

This is not the first patient I've sent home prescription-less. But it's the first time I've thought about it this way. In the past, I might've said to myself, the patient doesn't meet criteria, and therefore doesn't have the disorder in question, and consequently won't benefit from medication for this condition.

But now I'm reminded of the joke about the philosophy exam question, asking students to describe the physical characteristics of the chair at the front of the room. One student's response: What chair?

What disorder?

I came up with the following analogy: Suppose I decide that people who have more than 5 bad hair days per month carry a diagnosis of BHDD (Bad Hair Day Disorder). Am I describing an entity? Yes, people who have too many bad hair days. Does that make it a disorder, or disease?

I'm not sure the analogy is valid. At least some of the DSM diagnoses have a basis in clinical experience.

The truth is, and I realized this while I was writing, that I do find the DSM criteria for MDD useful, as a line of questioning.
This patient did not fit into any nice little DSM category. And I didn't try to make her fit. My thinking was, let's explore what she's been experiencing, using DSM criteria as a starting point. And that was useful.

I haven't purchased a copy of DSM-5. I don't want to. And I resent that, despite all the protests to the contrary, it remains the "bible" of psychiatry, and decisions are made based on its contents-reimbursement decisions, legal decisions.

But I do wish it could be what it professes to be: a guideline. Then it could sit on my book shelf with all the other books I use as references and guidelines, not with pride of place, and not with shame, either.

Learning from Diabetes

In a recent post, I wrote about how 126 became the cutoff for diabetes. It turns out that it was my fantasy about how 126 became the cutoff for diabetes. In response to the post, I got an email with a link to an article about the diagnosis of DM, which is, in the words of the person who sent it, "eerily like stuff going around re the DSM." I can't vouch for the accuracy of the article, but I'll summarize briefly.

A long time ago, back in the 70's, there were multiple standards for diagnosing diabetes. The reason for the multiple standards was that if you graph the sugars of a varied population at any given time, some will be elevated, but those don't necessarily correspond to the people who have diabetes.  Additionally, the graph never "jumps", so there's no clear cutoff point.

And at the time, there were limited treatments for diabetes, and essentially nothing to keep early type 2 from progressing. In addition, diabetes was quite stigmatized, and people with a diagnosis of DM could be refused health insurance, life insurance, employment, even a driver's license.

In 1978, the NIH convened a committee to establish a definition of diabetes, and the committee decided to place the cutoff higher than any standard had heretofore done, so that only people who unequivocally had DM would be given the diagnosis, and people who couldn't be helped anyway, such as early type 2 diabetics, would be spared the stigma, and its practical consequences.

And since a graph of a general population did not have a clear cut off point for DM, the committee looked at a subculture, the Pima Indians, whose graph did make a jump. Those Pima Indians whose Oral Glucose Tolerance Test was under 200 showed no symptoms of retinopathy, and those who did show signs of retinopathy had OGTT's over 240.

Then the committee decided to put the cutoff for fasting glucose at 140, higher than that of the typical diabetic Pima Indian, whose fasting glucose would hover around 120. Presumably this was done because at the time, OGTT was the test expected to be used to make a diagnosis, not fasting glucose.

In 1995, another committee was convened to re-examine the decision of the 1978 committee. This committee decided to use fasting glucose as the diagnostic test, presumably because it was cheaper, and it used a cutoff of 126, even though 121 seems to correspond with an OGTT of 200. They went with the highest number they could find in any study, specifically, a study of 13 Pacific populations.

There's more to the saga, but I'm gonna stop here with the diabetes. The take-home lesson for me is, Psychiatry is not such an outlier.

There are groups of people, including Gary Greenberg and his Book of Woe, who claim that Psychiatry is not as scientifically based as other medical specialties. Then there are other groups that claim it is scientific. Well, it appears to be at least as scientific as endocrinology.

A known disease entity, no one definitive diagnostic system, definition of disease determined by committee based on dubious scientific conclusions, the political stance not to further stigmatize people suffering from the disease, and a subsequent committee that examined the problems with the first committee's decisions, and then went on to make its own, new mistakes.

There is nothing new under the sun. A generation passes, and the world remains the same.

Read the article. It'll spook you. Even if it isn't accurate, it's exactly the same kind of rhetoric taking place now, about DSM-5.

Show Me The Science

I got this email yesterday:

NYSPA E-ALERT:  CONTACT YOUR LEGISLATOR TODAY REGARDING AUTISM BILL

All members are strongly encouraged to contact their local Assembly member or Senator today to oppose the passage of S.3044-A (Carlucci)/A.1663-A (Abinanti), a bill that would amend the Insurance Law and the Mental Hygiene Law to codify the DSM-IV definition of autism as the official definition of autism for the purposes of New York State law.  The proponents of the legislation seek to freeze the definition of autism because they are fearful that the new definitions in DSM-5 may diminish or eliminate eligibility for special education services in schools and/or health insurance coverage for community services.  This is simply not true and would be an improper intrusion of the Legislature into the realm of medical science.  Medical professionals must have the ability to update and revise clinical diagnoses according to new scientific evidence and advances in medicine. 


I'm gonna ignore, for now, the topic of what role the government should play in medicine, and focus on that last sentence: Medical professionals must have the ability to update and revise clinical diagnoses according to new scientific evidence and advances in medicine. 

Nu, so show me the science.

According to the DSM-5 description of the changes in criteria for Autism Spectrum Disorder:

The DSM-5 criteria were tested in real-life clinical settings as part of DSM-5 field trials, and analysis from that testing indicated that there will be no significant changes in the prevalence of the disorder. More recently, the largest and most up-to-date study, published by Huerta, et al, in the October 2012 issue of American Journal of Psychiatry, provided the most comprehensive assessment of the DSM-5 criteria for ASD based on symptom extraction from previously collected data. The study found that DSM-5 criteria identified 91 percent of children with clinical DSM-IV PDD diagnoses, suggesting that most children with DSM-IV PDD diagnoses will retain their diagnosis of ASD using the new criteria. Several other studies, using various methodologies, have been inconsistent in their findings. 

There didn't seem to be any reference or link to the "real-life clinical settings", and it seems like, if a "real-life" study was done, it would have been published, or pending publication, at least cited. But I did check out the Huerta paper, published in October, 2012. Here's the method:

Three data sets included 4,453 children with DSM-IV clinical PDD diagnoses and 690 with non-PDD diagnoses (e.g., language disorder). Items from a parent report measure of ASD symptoms (Autism Diagnostic Interview-Revised) and clinical observation instrument (Autism Diagnostic Observation Schedule) were matched to DSM-5 criteria and used to evaluate the sensitivity and specificity of the proposed DSM-5 criteria and current DSM-IV criteria when compared with clinical diagnoses.

I don't really understand what was done, and I'm not paying for the full article to figure it out.

These were the results:

Based on just parent data, the proposed DSM-5 criteria identified 91% of children with clinical DSM-IV PDD diagnoses. Sensitivity remained high in specific subgroups, including girls and children under 4. The specificity of DSM-5 ASD was 0.53 overall, while the specificity of DSM-IV ranged from 0.24, for clinically diagnosed PDD not otherwise specified (PDD-NOS), to 0.53, for autistic disorder. When data were required from both parent and clinical observation, the specificity of the DSM-5 criteria increased to 0.63.

Okay, sensitivity 91% or less ("remained high"), specificity 0.53 to 0.63.  I'm a little confused. You have 100 patients who were diagnosed with DSM-4 PDD, and 91 of them were diagnosed with DSM-5 ASD. Normally, you would use a sensitivity of 91% to establish that the new standard you're proposing is adequate, since it's almost as good as the old standard. So the diagnostic standard you're comparing to is DSM-4, and you're saying that since  DSM-5 is almost as good as DSM-4, it's better than DSM-4.

What would make sense is if there were a third standard, the Autism Standard, which was the basis for diagnosing Autism. If DSM-4 had, say, 80% sensitivity, and DSM-5 had 91% sensitivity, compared with the Autism Standard, then you could conclude that DSM-5 was more sensitive than DSM-4.

Alternatively, if they're saying that DSM-5 only picked up 91% of cases because 9% of DSM-4 cases are inaccurately diagnosed, then you need to question the basis for DSM-4 criteria, so you can't use it as a standard to compare DSM-5 to.

To belabor the point: Suppose you're testing lexapro vs. prozac, and comparing both to nortriptyline. If lexapro helped 80% of patients who were helped by nortriptyline, and prozac helped 95% of patients helped by nortriptyline, you could reasonably conclude that prozac works better than lexapro. But if you compare lexapro directly with prozac, and you find that lexapro helps 91 of the 100 patients that were helped by prozac, you can't conclude that lexapro works better than prozac.
And if you then claim that lexapro does work better than prozac because prozac didn't really help all the 100 people it claims to have helped, then you have no idea what prozac does and doesn't do, so what does it mean to say lexapro works better?

See what I'm getting at?

You could argue that DSM-5 has better specificity than DSM-4, but the whole concern is that people who have a DSM-4 diagnosis of PDD won't all have a DSM-5 diagnosis of ASD, so some will lose needed services/treatment. So the concern is about missing a real case, not misdiagnosing someone who doesn't have PDD. In other words, specificity isn't the issue.

Moving right along.

I looked up some of those "other studies" that have been "inconsistent in their findings".

This study, by McPartland, et al, published in April, 2012, found these results:

When applying proposed DSM-5 diagnostic criteria for ASD, 60.6% (95% confidence interval: 57%-64%) of cases with a clinical diagnosis of an ASD met revised DSM-5 diagnostic criteria for ASD. Overall specificity was high, with 94.9% (95% confidence interval: 92%-97%) of individuals accurately excluded from the spectrum. Sensitivity varied by diagnostic subgroup (autistic disorder = 0.76; Asperger's disorder = 0.25; pervasive developmental disorder-not otherwise specified = 0.28) and cognitive ability (IQ < 70 = 0.70; IQ ≥ 70 = 0.46).

The study concludes that:

Proposed DSM-5 criteria could substantially alter the composition of the autism spectrum. Revised criteria improve specificity but exclude a substantial portion of cognitively able individuals and those with ASDs other than autistic disorder. A more stringent diagnostic rubric holds significant public health ramifications regarding service eligibility and compatibility of historical and future research.


Another study found lower sensitivity and greater specificity, with sensitivity improving, although still less than DSM-4, if one DSM-5 criterion was relaxed.

Yet another study found lower sensitivity.

Let's see. We have "real-life" clinical settings without a linked study. We have one cited study demonstrating that some of the people with DSM-4 PDD diagnoses would lose those diagnoses under DSM-5, we have a statement that, "This is simply not true," and we have a sneaky little sentence dismissing, and not citing, those "other studies".

No, I don't think I will be contacting my local assembly member or senator.

WHO-Hoo!

Here's some good news for anyone who doesn't want to buy, read,
or use the DSM-5.

The World Health Organizatio (WHO) provides free online ICD-10 access, and free online ICD-10 training. I worked through most of the training, and it's a bit dull, but pretty intuitive.

Fittingly, Mental and Behavioral Disorders are in chapter V.

Here's a peak at how depression is described, ICD-10 style:

Depressive episode

In typical mild, moderate, or severe depressive episodes, the patient suffers from lowering of mood, reduction of energy, and decrease in activity. Capacity for enjoyment, interest, and concentration is reduced, and marked tiredness after even minimum effort is common. Sleep is usually disturbed and appetite diminished. Self-esteem and self-confidence are almost always reduced and, even in the mild form, some ideas of guilt or worthlessness are often present. The lowered mood varies little from day to day, is unresponsive to circumstances and may be accompanied by so-called "somatic" symptoms, such as loss of interest and pleasurable feelings, waking in the morning several hours before the usual time, depression worst in the morning, marked psychomotor retardation, agitation, loss of appetite, weight loss, and loss of libido. Depending upon the number and severity of the symptoms, a depressive episode may be specified as mild, moderate or severe.

Incl.:

single episodes of:

• depressive reaction
• psychogenic depression
• reactive depression

Excl.:

adjustment disorder (F43.2)

recurrent depressive disorder (F33.-)

when associated with conduct disorders in F91.- (F92.0)

F32.0Mild depressive episode

Two or three of the above symptoms are usually present. The patient is usually distressed by these but will probably be able to continue with most activities.

F32.1Moderate depressive episode

Four or more of the above symptoms are usually present and the patient is likely to have great difficulty in continuing with ordinary activities.

F32.2Severe depressive episode without psychotic symptoms

An episode of depression in which several of the above symptoms are marked and distressing, typically loss of self-esteem and ideas of worthlessness or guilt. Suicidal thoughts and acts are common and a number of "somatic" symptoms are usually present.

Agitated depression Major depression Vital depression

single episode without psychotic symptoms

Who-Hoo! No more Chinese menu!

ICD-10 codes are very different from ICD-9 codes, which are structured like DSM codes. Will insurance companies accept them? Looks like they will, starting October 1, 2014. Until then, ICD-9 will have to do.

Thanks, WHO.

Quick Link to Book Review

Here's a review of The Book of Woe: The DSM and the Unmaking of Psychiatry, by Gary Greenberg. For those who want more on the DSM-V saga.

The Other Winner

I haven't forgotten my promise to review the winners in my survey. Survey takers, god bless you, voted for chapter rearrangement as the change in DSM-5 that would do the most good. You can link to the full Table of Contents from here (sorry it's indirect).

Looking over the chapters there's really a lot to cover, especially if I'm trying to compare with DSM-4. So I thought I'd start with just the first clinical section in each.

DSM-5 begins with the general heading, Neurodevelopmental Disorders, and this section is broken down into subsections (which are further broken down). They are:

• Intellectual Disabilities
• Communication Disorders
• Autism Spectrum Disorder
• ADHD
• Specific Learning Disorder
• Motor Disorders
• Other 

The corresponding section of DSM-4 is called, Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence with these sections:

• Mental Retardation
• Learning Disorders
• Motor Skills Disorder
• Communication Disorders
• PDD
• ADHD
• Feeding and Eating Disorders of Infancy or Early Childhood
• Tic Disorders
• Elimination Disorders
• Other

I'm not sure which I prefer. In DSM-5, Tic Disorders are included under Motor Disorders, rather than having their own section as in DSM-4. Learning Disorders are broken down into specific disorders in DSM-4, while in DSM-5 they're not. And, of course, DSM-4 includes multiple Pervasive Developmental Disorders, where DSM-5 groups all under the heading of Autism Spectrum.

In addition, DSM-5 puts all feeding and eating disorders, regardless of developmental stage, into their own section, entitled, unsurprisingly, "Feeding and Eating Disorders", and this section occurs much later in the book. It's immediately followed by the Elimination Disorders section, which removes the implication of these as childhood disorders.

So it's looking like DSM-5 does more lumping, where DSM-4 did more splitting. But that's not entirely consistent.

And you have to admit, there's a nice logic to following the Eating chapter with the Elimination chapter.

One thing I do like about the chapter organization in DSM-5 is that, unlike DSM-4, Neurodevelopmental disorders, which are basically childhood disorders, are not followed immediately by delirium and dementia, disorders of old age.

I'll cover more in future posts because it's getting past my bedtime.

And In This Corner....

Get ready to rumble!

Meet the contender: Thomas Insel, MD of NIMH

And the reigning champion, David Kupfer, MD of the DSM-5

Dr. Insel comes out swinging with the Research Domain Criteria (RDoC), the project launched by NIMH "to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system."

And, wait for it, "..it is critical to realize that we cannot succeed if we use DSM categories as the 'gold standard'...The diagnostic system has to be based on the emerging research data, not on the current symptom-based categories."

Ooooh, low blow.

Now Dr. Kupfer counters with, "Efforts like the National Institute of Mental Health’s Research Domain Criteria (RDoC) are vital to the continued progress of our collective understanding of mental disorders. But they cannot serve us in the here and now, and they cannot supplant DSM-5. RDoC is a complementary endeavor to move us forward, and its results may someday culminate in the genetic and neuroscience breakthroughs that will revolutionize our field. In the meantime, should we merely hand patients another promissory note that something may happen sometime?"

Dr. Insel staggers backward into the ropes. He's covering up with his gloves. But wait, he shoves Dr. Kupfer away and pummels him with, "That is why NIMH will be re-orienting its research away from DSM categories. Going forward, we will be supporting research projects that look across current categories – or sub-divide current categories – to begin to develop a better system."

And Dr. Kupfer is down! The grant money gets 'em every time.


* I hope the Ali-Frazier image is old enough (1974) to be off copyright. If not, I'll promptly remove it, with my apologies.

Bereavement

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-5; Arch 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!

 

And The Winner Is...

The results of my completely non-scientific and woefully under-sampled survey are in. Thanks to everyone who filled it out, and for those of you who didn't, I haven't lost faith in you for next time, whenever that turns out to be.

Drumroll, please (percentages rounded):

1. Which change in the new DSM-5 (as opposed to the old DSM-5) do you think will do the most harm?

Bereavement-66%
Binge Eating-11%
Disruptive Mood Regulation Disorder-11%
Removal of Multi-Axial System-11%
Others-0%

2. Which change in DSM-5 do you think will do the most good?

Chapter Rearrangement-33%
Gender Dysphoria-22%
Hoarding-22%
Substance-11%
Removal of Multi-Axial System-11%
Others-0%

3. Do you plan to buy the DSM-5 when it's released?

No-44%
Yes-33%
Unsure-22%

4. Do you think DSM-5 will change the way you practice?

No-78%
Yes, in a bad way-11%
Unsure-11%
Yes, in a good way-0%

Since I didn't ask people to explain their reasoning in the survey, I don't know why they feel the way they feel. However, I'm going to empathically place myself in the minds of those who voted for the winners, and try to write about why I, as them, would have chosen as I did, and also about what the literature shows. FYI, not all of the results agreed with my own opinion, but I think the occasional exercise in empathy is a good thing.

I'll cover Bereavement and Chapter Rearrangement in another post, but I just want to comment on the last two results. Think about it. Most people do not plan to buy the new DSM, and no one thinks it's publication, nay, existence, is a good thing.

Um, APA, you worked on this for years, with all the attendent Sturm und Drang, and no one thinks it'll do any good. What gives?