In DSM-IV, a “diagnosis” of major depressive disorder is based on the presence of a major depressive episode.
A major depressive episode, in turn, is defined by the presence of five or more items from the following list during a two-week period:
(1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.
(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
(3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
(4) insomnia or hypersomnia nearly every day
(5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
(6) fatigue or loss of energy nearly every day
(7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
(8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
(9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide (DSM-IV p 327)
For the “diagnosis” to be made, the “symptoms” must cause clinically significant distress or impairment in social, occupational or other areas of functioning.
In addition, there are three exclusions. A “diagnosis” of major depressive disorder is not to be made if:
– the “symptoms” meet the criteria for a mixed episode
– the “symptoms” are due to a substance or a general medical condition, or
– the symptoms are due to bereavement
This latter item is called the bereavement exclusion, and the APA has decided to drop this exclusion from the DSM-5. This decision generated a good deal of debate, and I thought it might be helpful to examine the issue in some detail.
The DSM-IV wording is interesting. The “diagnosis” can and should be made unless the symptoms are “… 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 functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.”
The language is somewhat convoluted, but you can clearly see that the exclusion is only partial. The “diagnosis” can be made if:
1. the bereavement lasts more than two months
2. or, there is marked functional impairment
3. or, morbid preoccupation with worthlessness
4. or, suicidal ideation
5. or psychotic symptoms
6. or psychomotor retardation
In other words, the bereavement exclusion does not apply if any one of these six items is present.
What’s troubling about all this is that it’s difficult to imagine (or at least I find it difficult to imagine) a bereavement in which at least one of these factors wouldn’t be present. In fact, I suggest that in most cases of bereavement, four, five, or even all six factors would be present. Think about it!
– lasts more than two months [yes]
– marked functional impairment [yes]
– morbid preoccupation with worthlessness [maybe]
– suicidal ideation (thoughts, not necessarily action) [probably]
– psychotic symptoms (I’ve never known a bereaved person who didn’t at some point hallucinate the loved one’s voice) [likely]
– psychomotor retardation [definitely]
What I’m getting at here is that there never was a bereavement exclusion in DSM-IV!
Compare this to DSM-III-R: “Uncomplicated Bereavement is distinguished from a Major Depressive Episode and is not considered a mental disorder even when associated with the full depressive syndrome.” (p 222) This is a bereavement-exclusion and is pretty clear, though they did muddy the waters a little, later in the text. In the DSM-IV, the bereavement exclusion is effectively gone, though the appearance of a bereavement exclusion is retained. Probably because of this appearance and the convoluted language, it was widely believed in mental health circles that a “diagnosis” of major depression could not be assigned in cases of bereavement, and in practice this “diagnosis” was usually only assigned in cases where the bereaved person attempted suicide. In DSM-5, even the appearance is to be deleted.
In their “Highlights of Changes…“ document, the APA lists four reasons for omitting the bereavement exclusion from DSM-5:
1. “…to remove the implication that bereavement typically lasts only 2 months”
2. “…bereavement is recognized as a severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual…”
3. “…bereavement-related major depression is most likely to occur in individuals with past personal and family histories of major depressive episodes.”
4. “…the depressive symptoms associated with bereavement-related depression respond to the same psychosocial and medication treatments as non–bereavement-related depression.”
The APA continues:
“In the criteria for major depressive disorder, a detailed footnote has replaced the more simplistic DSM-IV exclusion to aid clinicians in making the critical distinction between the symptoms characteristic of bereavement and those of a major depressive episode. Thus, although most people experiencing the loss of a loved one experience bereavement without developing a major depressive episode, evidence does not support the separation of loss of a loved one from other stressors in terms of its likelihood of precipitating a major depressive episode or the relative likelihood that the symptoms will remit spontaneously.”
There are a number of noteworthy points. Firstly, the four reasons given for the change do not – at least in my view – seem very compelling. In the context of the six decades of “diagnostic” expansion, this just seems like more of the same: bereavement is now a mental illness because the APA say so.
Although the APA state that most episodes of bereavement will not develop into a major depressive episode, it is clear that the great majority of people who have lost a loved one will in fact fall into this category and will receive a “diagnosis” of major depressive disorder. I can’t imagine a bereaved person not meeting five or more of the depressive episode criteria listed earlier. And remember, the criteria have to be met for only two weeks!
In my view the essential dynamics of the matter are as follows. DSM-IV did not have a bereavement exclusion, but did have the appearance of a bereavement exclusion (presumably for window dressing). Most psychiatrists took the apparent exclusion seriously and didn’t usually assign a “diagnosis” of major depression in cases of bereavement. In DSM-5, this problem will be fixed. So old-fashioned do-it-yourself-with-the-help-of-family-and-friends grieving will be a thing of the past.
About 2.5 million people die in the US each year, and it is reasonable to assume that almost every one of these will leave at least one bereaved person behind. This is an enormous under-tapped market for the pharmaceutical industry. But don’t worry; their friends in the APA are on the job.
And don’t forget, 69% of the APA’s DSM-5 work group members have financial ties to pharma. But the APA have assured us that this didn’t influence their professional judgment in the slightest.
Once again, I find myself asking where do they get the gall? How dare they presume to decide whose bereavement is “normal” and whose is pathological!?!
They aren’t going to stop until they have everybody diagnosed and everybody on drugs. They are purely and simply out of control.