Health Letter, May 2013
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is considered the bible for classifying psychiatric diagnoses and, consequently, for prescribing drugs to treat these disorders. It is intended primarily for psychiatrists but is used by professionals in many other medical disciplines. When the latest version — the fifth edition, called the DSM-5 — is published in May 2013, it will reflect a controversial change at the heart of a long-simmering debate among psychiatrists: Do people suffering from the recent loss of a loved one need an antidepressant to prevent major depression, or will time and the support of friends and family help them recover without the use of drugs?
The fourth version of the DSM, the DSM-IV, states that grief is a normal response to loss of a loved one, from which people will recover over time with help from family and friends — and without the need for antidepressant therapy. The so-called “bereavement exclusion” included in the DSM-IV states that the behaviors exhibited during the first few months of experiencing grief are excluded from being labeled as signs of major depressive disorder (MDD).
With the new publication of the DSM-5, a few psychiatrists have pushed hard, successfully, to change that sentiment by eliminating the bereavement exclusion. In their eyes, grief should be on the table for categorization as MDD, therefore rationalizing treatment with antidepressant drugs.
Revision authors and a potential conflict of interest
The Mood Disorders Work Group rewriting the DSM for 2013 was headed by Dr. Jan Fawcett, professor of psychiatry at the University of New Mexico, who in turn nominated the rest of the 11-member panel. One of the most significant members working on the bereavement exclusion was Dr. Sidney Zisook, a psychiatrist at the University of California, San Diego. Dr. Zisook has long studied bereavement issues and became the main force and key adviser on the Mood Disorders Work Group, as well as the individual primarily responsible for writing the new guidelines.
Dr. Zisook has written extensively on the subject of grief, including a major paper that he co-authored with a fellow member of the Mood Disorders Work Group, Dr. Kenneth Kendler, and published in 2007 in Psychological Medicine. Their review analyzed studies up to November 2006 (no starting date was provided). The Zisook and Kendler paper carried great weight in the revision process: It became the major reference supporting the new changes, as noted by one of the editors of the DSM-IV.
Zisook and Kendler stated at the end of their 2007 paper that “some subjectivity may have influenced which studies were included and how some of the data may have been interpreted. Few of the available studies used structured interviews, and even fewer incorporated the most appropriate control groups to answer our key question.”
Nevertheless, they concluded that this data supported their proposed revision, stating that:
Although the definitive study has yet to be completed, the preponderance of available data supports the hypothesis that BRD [bereavement-related depression] resembles typical cases of SMD [standard (nonbereavement-related) major depression] and therefore should be considered instances of SMD.
Essentially identical language was published the same year in the conclusions to another paper by Dr. Zisook and colleagues on this same subject.
In one of these 2007 reviews, Dr. Zisook listed himself as an adviser to GlaxoSmithKline (GSK) and a recipient of honoraria from GSK and Forest Laboratories, both manufacturers of antidepressant drugs. The Mood Disorders Work Group chairman, Dr. Fawcett, felt that financial ties to industry had no bearing on the work at hand, stating, “I don’t think these connections create any bias at all. People can say we were biased. But it assumes we have no intelligence of our own.
The principles established in the Institute of Medicine’s landmark 2009 report, Conflict of Interest in Medical Research, Education, and Practice are emphatic in stating that professional societies should “generally exclude individuals with conflicts of interest from the panels that draft the guidelines.” This is due to the extensive influence such guidelines have in affecting “physician practice, quality measures, and insurance coverage decisions.
Opponents to the revision
On the other side of the bereavement-exclusion issue are the opinions of, among others, Dr. Allen Frances, chairman of the task force that created the DSM-IV. Now an emeritus professor at Duke University, Dr. Frances has been outspoken against the DSM-5’s changes, fearing that “the revisions will medicalize normality and that millions of people will get psychiatric labels unnecessarily.” Dr. Robert Spitzer, who oversaw the set of revisions that became the DSM-III, also has expressed concern, joining psychiatrists Dr. Jerome Wakefield of New York University and Dr. Michael First of Columbia University.
Dr. Frances is especially concerned that the change to the bereavement exclusion will promote overdiagnosis and overtreatment, with drug companies all too eager both to market drugs to physicians and convince the grieving that they need pharmaceutical help.
In an opinion piece published in The New York Times, he expressed additional fears of further ramifications, such as the notion that people receiving an MDD diagnosis might have difficulty getting a job or health insurance. Dr. Frances also stated that because most people recover from grief without antidepressants, once they begin taking the drugs, they may believe that it was the medicine that caused their recovery and feel compelled to continue taking them. Besides being expensive, antidepressants can cause serious side effects, and medication that was unneeded in the first place can end up causing physical harm.
Dr. Wakefield and Dr. First share Dr. Frances’s concerns and feel strongly that the bereavement exclusion should remain in DSM-5. They even feel it should perhaps be lengthened in duration, such that an MDD diagnosis would not take place until after the currently specified time frame of two months. Both doctors emphasize the importance of distinguishing between the normal, intense grief caused by bereavement and major depression. They recommend improving the wording of the bereavement exclusion, proposing that the text list specific features that distinguish major depression from normal grief, such as suicidal ideation and morbid preoccupation with worthlessness. They state that the text as written can be misinterpreted by clinicians not trained in grief counseling.
Furthermore, Wakefield and First suggest adding “other life stressors,” such as divorce or job loss, as additional circumstances to be excluded from MDD diagnosis. In other words, they believe individuals should have a chance to recover from difficult life events with the help of family and friends before starting treatment for a major depressive episode. They conclude an analysis of the Zisook et al. papers by stating that there is no empirical evidence supporting the proposed change to the DSM which thus “has no basis in scientific fact.”
Nevertheless, in December 2012, the American Psychiatric Association unfortunately voted in favor of changing the DSM, thereby embracing the suggestion that treatment with antidepressants would be the best approach to bereavement for many people.
Public Citizen agrees with those psychiatrists favoring the less medicalized approach to bereavement. The use of antidepressants should be reserved for those who, after an adequate period of very normal, natural grieving, do not respond to the healing influences of support and time.
Understanding and supporting the process of grief
It may be true that every person has a unique reaction to losing a loved one, but grief itself is a normal, adaptive process that allows the affected person eventually to get on with life. Recent studies have shown that feelings of grief can persist for many years, and some think they can last a lifetime. In most cases, grief does not need to be “medicalized.”
Grief is frequently described as occurring in phases, one following the other. Some people move back and forth between phases, and the boundaries between the phases may be blurred.
- Phase 1 begins immediately after the loss and may last up to a few weeks. The survivor experiences shock, numbness and disbelief, accompanied by crying, sighing, throat tightness and a sense of unreality.
- Phase 2 is characterized by preoccupation with the deceased, a yearning to recover the lost person and an examination of the past relationship, including disagreements, conflicts and unresolved anger. Wildly changing emotions and intense dreams of the deceased may be experienced, as well as physical weakness and fatigue. (If this phase extends beyond several months and does not progress to further stages, it may signal the need for treatment, as a prolonged continuation of this stage constitutes pathological, or abnormal, grief.)
- Phase 3 is characterized by disorganization and despair but also acceptance of the permanence and the fact of loss. Sadness persists in this phase, along with feelings of emptiness and loss of interest in usual activities.
- Phase 4 involves resolution and reorganization of behavior, in which normal activities and interests resume. Occasional feelings of sadness and emptiness, as well as crying spells, may occur, but less frequently than before or with less intensity.
Familiarizing yourself with the natural, common phases of grief, and possibly recognizing in them your own feelings and behaviors, could help you to understand that a potentially risky pharmaceutical approach to handling grief may not be necessary.
Support groups and counseling, from family and friends or a mental health professional, may help you pass through the phases of mourning by accepting the reality of the loss, dealing with feelings and emotions, and readjusting to the new landscape.
In 1984, the Institute of Medicine and National Academy of Sciences released a landmark report entitled Bereavement: Reactions, Consequences, and Care. The report recommended the implementation of a series of societal supports involving:
- Health professionals and institutions, which have a continuing responsibility to the bereaved;
- Schools, which should train nurses and physicians to look for warning signs and refer people to counseling; and
- Social workers and chaplains, who should be made available in hospital settings.
Additionally, the report stated that increased public education could help offer support indirectly to bereaved persons, noting that many people are surprised by the intensity of the emotional reaction to the death of a loved one.
A network of care for those experiencing grief, as well as a basic understanding of what to expect, can offer crucial aid in helping the bereaved overcome suffering.