Beyond DSM-IV Bereavement Exclusion Criterion E for Major Depressive Disorder

Abstract

ticle, we propose to revise DSM-IV bereavement exclusion and keep the V code for bereavement as suggested by Paula Clayton [19] . In addition, in the event that criterion E is deleted, we believe that criterion A for major depression should be revised to require at least 7 of the 9 criterion A inclusion symptoms for MDE in all types of MDD, which would satisfy the concerns raised by Lichtenberg and Belmaker [3] and Bech [4] about the overinclusiveness of criterion A, leading to overdiagnosis of MDE. Adjusting the number of inclusion symptoms of criterion A reinforces the dimensional approach to depression initiated by the DSM-III (1980) and DSM-III-R (1987). To avoid a 'single catchall entity' diagnosis of MDE [3] , depression subtypes can be used, including bereavement depression. Now is the time to reevaluate depression subtypes and MDD, and allow subtypes for some of the welldefined stress event depressions. Bereavement and Major DepressionBereavement is known to be associated with high rates of MDE and of other major depressive syndromes [20][21][22][23][24][25][26][27][28][29] . Major depression is common during the first year of bereavement, with higher rates earlier in bereaveThere are two issues facing the DSM-V in the revision of the criteria for major depressive disorder (MDD), the first being the concept of DSM-III [1] criterion A inclusion symptoms for major depressive episode (MDE), which has recently been addressed by Fava et al. [2] , Lichtenberg and Belmaker [3] and Bech [4] . The second concerns bereavement criterion E, which often leads to exclusion from MDE. The rationale behind criterion E was that symptoms of bereavement-related sadness resemble those of major depression without the presence of MDD. Bereavement is the only stressful life event (SLE) which is an exclusion criterion for a DSM axis I diagnosis, unless depressive symptoms associated with bereavement last longer than 2 months or meet the bereavement descriptive E criterion for major depression. Several authors have questioned the validity of excluding bereavement from major depression when all other inclusion criteria are met [5][6][7][8] . SLE, including bereavement, have been found to contribute to, initiate and maintain MDD [9][10][11][12][13][14][15][16][17] . More recently, we reported that DSM-IV bereavement-excluded subjects were more severely depressed than MDE subjects without bereavement, and at least as severely depressed as MDE subjects with bereavement [18] . At this time, the DSM-V is proposing to delete bereavement exclusion criterion E for major depression (www.DSM5.org). In the present ar-

Subtyping demoralization in the medically ill by cluster analysis

“…If the loss of pleasure and interest becomes very severe and pervasive, demoralization can follow 37 . Therefore, demoralization in major depressive patients may represent a psychological response to a prolonged and severe loss of interest and pleasure 48 . However, in other medically ill patients the relationship between major depression and demoralization might be characterized by a different sequence.…”

Do Clinical Psychologists Extend the Bereavement Exclusion for Major Depression to Other Stressful Life Events?

“…Of course, additional practical proposals have been offered that largely sidestep the issue of consideration of stressful life event context in assessment of MDD while still addressing the potential issue of overdiagnosis should the bereavement exclusion criterion be removed. For example, Chouinard and colleagues 14 proposed that the exclusion should be removed, but the criteria should be revised to require at least 7 out of 9 symptoms instead of the current 5 out of 9. To increase overall diagnostic accuracy, Gopal and Bursztajn 42 more broadly recommend a complete reformatting of the DSM system to integrate symptom weights, narrative descriptions, and dimensional scales with the “checklist” rule-based style of the current DSM (e.g., “x symptoms out of y”), although such proposals would remain to be systematically tested against the current system.…”

“…The first camp proposes that the bereavement exclusion criterion should be removed completely from the manual, so that MDD is diagnosed more purely with respect to the presence of current symptoms, marked distress, and impairment. 9,10,14–16 The justifications in the literature for this change are complex and encompass a range of views, but one key justification is that once the threshold for disordered symptoms, as defined by the DSM , is met, it indicates that a breakdown in functioning has occurred. From this perspective, there is no need to assess the behaviors with reference to life event context because the behaviors in and of themselves reflect dysfunction and suffering and thereby warrant clinical attention.…”

When does depression become a disorder? Using recurrence rates to evaluate the validity of proposed changes in major depression diagnostic thresholds

“…It has been suggested that the MDD threshold should be raised to seven symptoms from the current five “to lower the risk of ‘over‐diagnosis’ or pathologizing ‘normal’ depression or sadness” . This proposal is supported by findings over the years suggesting a discontinuity between MDD episodes with five to six and seven to nine symptoms .…”