Psychiatrists To Take New Approach In Bereavement

A panel of psychiatrists recently voted on changes for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. It guides diagnoses and treatments for millions of people. Among the changes is the removal of the so-called "bereavement exclusion" for depression diagnoses. Audie Cornish talks with Jerome Wakefield of NYU's Silver School of Social Work and Department of Psychiatry, about how it might change the way doctors deal with grieving patients.

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AUDIE CORNISH, HOST:

From NPR News, this is ALL THINGS CONSIDERED. I'm Audie Cornish.

MELISSA BLOCK, HOST:

And I'm Melissa Block.

This past weekend, a task force of psychiatrists made some big decisions. They sat down and voted on what to include and not to include in the new version of the Diagnostic and Statistical Manual of Mental Disorders, the DSM Fifth Edition. It's the book that sets the basic standards for psychiatric diagnoses. This is the first time it's been updated since 1994.

CORNISH: We're going to talk now about one controversial change to the manual. It's about how doctors approach depression in the case of a patient grieving over the loss of a loved one.

For more, we're joined by Jerome Wakefield. He's from the School of Social Work and Department of Psychiatry at New York University. Jerome, welcome to the program.

JEROME WAKEFIELD: Thank you.

CORNISH: So first, let's spell out this change. It involves removing from the manual something called the bereavement exclusion. So start by explaining what that is.

WAKEFIELD: Right now, major depression is diagnosed by a list of symptoms. If you have five out of these symptoms for two weeks, you have major depression. Symptoms include: sadness, loss of appetite, insomnia, fatigue, lack of interest in your usual activities, and so on.

However, it was noticed that when the new criteria were created that many people who have grief feel these same feelings, normal grief. And, in fact, research has shown that this is true. So the idea was let's put in a criterion that says don't diagnose major depression in an individual even if they have these kinds of feelings if they just lost a loved one.

Instead of just two weeks that's allowed for the symptoms usually, the bereavement exclusion says don't diagnose them as having a psychiatric disorder unless these feelings go on for at least two months.

CORNISH: So this past weekend, the DSM panel voted to remove the bereavement exclusion. And to kind of summarize the argument for that, basically there was a concern that grieving patients with severe symptoms were actually being prevented from getting proper treatment because they fell within this exclusion. And doctors, I guess would say to them, no, this is just normal grieving.

But I take it that you disagree.

WAKEFIELD: That's right. I mean, as I just explained it, the bereavement exclusion - as it has been in the manual since 1980 - doesn't say you shouldn't diagnose anybody with depression just because they recently lost somebody. What it says is that we're going to make a distinction between the ones that should diagnose and the ones that you shouldn't diagnose.

So, to me, it doesn't really make sense to - on the basis of worrying that you're going to miss a case that's more severe - to eliminate the bereavement exclusion, because the bereavement exclusion already takes account of the fact that anybody who's severe should be diagnosed anyway.

Now, keep in mind that what this means is that now without the exclusion the limitation is two weeks, the normal period of time allowed for depressive feelings before you're diagnosed - for anybody. That means that after you lose a loved one - you lose a spouse, a parent, even a child - if two weeks later, you are feeling things like sadness, lack of interest in your usual activities, fatigue, insomnia, loss of appetite, these kinds of symptoms that are routinely contained in a response to extreme loss, then you will be diagnosable with a mental disorder.

To a lot of us this just seems like a gross error of psychiatric classification that might allow patients to be given meditation, to be diagnosed, to be seen differently than for what they really are going through.

CORNISH: And is that your concern here, that this will bring too many people into the fold?

WAKEFIELD: Once this is on the books as a legitimate mental disorder, it will be targeted for drug development and treatment will be much more routine. People will be seen differently by their own families and they're diagnosed with a mental disorder. People will see themselves differently. So, yes, I think this will be quite dramatic.

One of the main motivations for eliminating the bereavement exclusion was the idea that medication might help. So we can look forward, if you will, to a time when medication will be given more routinely to people who are grieving; even when they have a relatively mild depressive feeling during that grief.

CORNISH: Is that necessarily a bad thing?

WAKEFIELD: I think right now we do not actually know that this helps, that medication helps. This belief is ahead of the curve with respect to research. We also know from the research that people who are having these milder depressive feelings during grief don't have a recurrence of depression. They seem to do very well. They get over it and they go on, and they're not recurrent like usual depression is. So you're basically medicating people who are going to remit on their own, are probably going to do fine.

I think given the side effects of medications, the uncertainties of medication, it's a mistake to make it routine to open up people to medication under these circumstances. We do want to help people who are suffering, but to re-label suffering as a mental disorder - subjected to psychiatric treatment - seems like opening the door to a very different way of thinking about ourselves and people that might not actually be so helpful after all.

CORNISH: Jerome Wakefield, thank you so much for speaking with me.

WAKEFIELD: Thank you.

CORNISH: Jerome Wakefield, he's from the Social of Work and Department of Psychiatry at New York University. He's also the co-author of the book "The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder."

BLOCK: Doctor Wakefield was talking about one change to the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM. Here are a few others.

CORNISH: The diagnosis of Asperger's will disappear in favor of a broader category. It's called Autism Spectrum Disorder. People with Asperger's will be placed on the mild side of that spectrum.

BLOCK: A new diagnosis was added to the manual, Hoarding Disorder. It describes people who find it very difficult to part with any possessions, no matter how worthless they are.

CORNISH: Binge Eating becomes a full-fledged disorder. Previously it was considered a behavior that required more study. But the experts decided it now qualifies for the manual.

BLOCK: And finally, here's something to watch for in the future. The DSM panel lifted something called Internet Use Gaming Disorder. It's a disorder that needs additional research. That means in the coming years, experts will be trying to decide if the addictive playing of online games - or the compulsive use of the Internet generally - could qualify as a mental illness.

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