DSM Debate Grows over Grief and Depression

A recent New York Times article highlights a growing controversy over the next version of the Diagnostic and Statistical Manual (commonly called "the DSM"), which is the bible of classifications of mental disorders in the United States.

Even as it is due at the printers in December, new material planned for DSM-V is being intensely debated, including the proposed elimination of the current exclusion from a diagnosis of depression for a person experiencing grief:

Under the current criteria, a depression diagnosis requires that a person have five of nine symptoms -- which include sleeping problems, a feeling of worthlessness and a loss of concentration -- for two weeks or more. The criteria make an explicit exception for normal grieving, which can look like depression (Benedict Carey - "Grief Could Join List of Disorders" - New York Times - 01/24/2012).

On one side of the argument are those who believe the current exclusion does a disservice to grieving people who would benefit from a diagnosis of (and treatment for) depression:

“If someone is suffering from severe depression symptoms one or two months after a loss or a death, and I can’t make a diagnosis of depression, [says Dr. David Kupfer, professor of psychiatry at the University of Pittsburgh School of Medicine,] well, that is not being clinically proactive. That person may then not get the treatment they need” (Carey).

On the other side are those who fear that grief will come to be considered as an illness:

“An estimated 8 to 10 million people lose a loved one every year, and something like a third to a half of them suffer depressive symptoms for up to month afterward,” [says Dr. Jerome Wakefield of New York University]. This [eliminating the exclusion] would pathologize them for behavior previously thought to be normal” (Carey).

Certainly, then, as final approval of the new DSM moves toward a conclusion, differing views of the science and research behind understanding grief and depression are going to come to the foreground.

Here are two examples of recent journal articles, for and against, respectively, eliminating the depression exclusion for grief:

• Dr. Kristi Lamb and her co-authors in a recent article in Psychiatry state, "we believe that the best available data do not support the validity of the current DSM-IV bereavement exclusion" (Lamb - The Bereavement Exclusion for the Diagnosis of Major Depression: To Be, or Not to Be - Psychiatry - July 2010).
• A newly published report in World Psychiatry of a study by NYU's Dr. Wakefield and Dr. Michael First of Columbia University states, "the literature does not support the invalidity of the [bereavement exclusion] or its elimination from DSM-5" (Wakefield - Validity of the Bereavement Exclusion to Major Depression: Does the Empirical Evidence Support the Proposal to Eliminate the Exclusion in Dsm-5? - World Psychiatry - February 2012). The article goes on to recommend that several less drastic modifications to the exclusion -- instead of its elimination -- be included in DSM-V.

Medscape News Today published a seven-part series in April 2011 about the debate, featuring extensive commentary from Dr. First (Dr. Wakefield's co-author), who opposes removing the exclusion, and Dr. Sidney Zisook and Dr. Ronald Pies (Lamb's co-authors), who support removing the exclusion. (Medscape access requires registration, which is free.)

[CORRECTION: An earlier version of this post incorrectly stated Dr. Pies's position on the exclusion. For readers who would like to read more about the "inner world" of grief and depression, please see his article "The Two Worlds of Grief and Depression." FJC]

By Franklin Cook, SAVE, Director of Survivor and Bereavement Programs
This article may be linked to at suicidegrief.save.org/node/2981, or reprinted in its entirety without permission -- but not for commercial purposes -- as long as the author credit and copyright notice are included.
© 2012, SAVE -- Suicide Awareness Voices of Education