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Dr. Bob is Robert Hsiung, MD,
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Posted by Phillipa on December 5, 2008, at 21:26:13
Interesting article on losses. Phillipa
Bereavement-Related Depression Identical to Other Depression Types
DSM-IV Exclusion for Bereavement Should Be Revised
Marlene Busko
December 4, 2008 Major depression related to bereavement is essentially identical to major depression brought on by other stressful life events, suggesting that it should not be excluded from standard depression diagnoses, new research suggests.Currently, the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), assigns special status to bereavement-related depression, claiming it is distinct for all other depressive episodes. However, these latest findings challenge this assertion.
"Depression that occurs in the context of the loss of a loved one is essentially identical to depression that occurs in the context of any other negative event or loss," study coauthor Sidney Zisook, MD, from the University of California at San Diego, told Medscape Psychiatry.
The study, led by Kenneth S. Kendler, MD, from Virginia Commonwealth University Medical School, in Richmond, was published in the November issue of the American Journal of Psychiatry.
"If a bereaved person's depression otherwise meets criteria for major depression, it should be taken seriously, diagnosed as major depression, and treated accordingly, rather than continuing to use the bereavement-exclusion rule and treating this as 'normal grief'," said Dr. Zisook.
Bereavement is the only predisposing stressful life event that is singled out in the DSM-IV. To determine the validity of distinguishing normal grief from major depression associated with other stressful life events, the researchers examined a large population-based sample of twins.
They identified 82 individuals with confirmed bereavement-related depression and 224 individuals with depression related to stressful life events, including divorce/separation (167), illness (36), and job loss (21).
Similarities Outweigh Differences
A total of 23 people (28%) with bereavement-related depression met the DSM-IV criteria for normal grief, but a similar proportion of people with depression unrelated to bereavement, 55 people (25%), also met these criteria.
"The 2 groups were similar in many important ways, including duration of the index episode, the frequency of severe impairment, [and] the clinical severity of the episode," the researchers report.
"The similarities of bereavement-related depression and depression related to other stressful life events far outweigh their differences. We were unable to show, as predicted by DSM, that cases of depression meeting criteria for both bereavement-related depression and 'normal grief' were unique in any way. On their face, these results argue against the continued use of the 'bereavement-exclusion rule' in the DSM-V," the authors write.
Treatment decisions depend on the severity and persistence of the depression, as well as the patient's history, so not every bereaved individual who meets the criteria for major depression needs to be treated with medications right away, said Dr. Zisook.
"But if the individual meets the criteria for major depression, you don't do him or her a favor by ignoring the symptoms and saying, 'Oh, that's just normal grief.' Unrecognized or untreated major depression can have serious consequences," he said.
Another Point of View
Investigators at New York University, led by Jerome C. Wakefield, PhD, DSW, also found many more similarities than differences between bereavement-related depression and depression related to other stressful life events (Arch Gen Psychiatry. 2007;64:433-440), but came to a "dramatically different" conclusion.
Instead of dropping the bereavement-exclusion rule, they suggest extending the exclusion to all episodes of uncomplicated life-event-precipitated depressive episodes.
"The bereavement exclusion is too narrow," Dr. Wakefield told Medscape Psychiatry. "It ought to be extended to cover similar not-too-long, not-too-severe reactions to other major stressors in life."
According to Dr. Wakefield, uncomplicated bereavement is clearly not disordered, and looks similar to uncomplicated reactions to other stressors.
Opposite Proposals
In an accompanying editorial, Mario Maj, MD, from the University of Naples, in Italy, says that the conflicting recommendations by the 2 research groups are likely to be divisive.
"These opposite proposals based on the same research are likely to divide our field and the public opinion for several years," he writes.
"Of course, both proposals have significant treatment implications. On the one hand, the risk is to medicalize an adaptive response, thus disrupting the individual's coping processes. On the other, the risk is to deprive a person with full depressive syndrome of a treatment that may be needed."
Dr. Maj continues: "At the present state of knowledge, it may be therefore unwise to disallow the diagnosis of major depression in a person meeting the severity, duration, and impairment criteria for that diagnosis just because the depressive state occurs in the context of a significant life event."
"On the other hand, the removal of the bereavement-exclusion criterion from the DSM-V diagnosis of major depression a move that may be perceived as a further step in psychiatry's attempt to pathologize normal human processes requires strong and unequivocal research evidence," Dr. Maj notes.
However, Dr. Maj believes that before a decision to remove the bereavement-exclusion criterion from the future editions of the DSM is made, the results of the current study should be validated in various groups and scenarios young vs old, impact of losing a close relative vs a friend, etc.
Posted by yxibow on December 6, 2008, at 0:07:05
In reply to Bereavement Depression Treat Same As Major Deprssi, posted by Phillipa on December 5, 2008, at 21:26:13
I think its a divergence between whether the person bereaving is also subject to a biochemical imbalance or whether they have depression in what is basically a post-traumatic experience that is not based on any original depression.
But that probably doesn't matter since what is environmental, psychological, and biochemical converges at the same place often.
So the argument I guess can be digested that it probably doesn't matter what the depressive state is if it meets criteria X for condition Y of DSM-IV-TR. I think that's the major argument here for the DSM-IV in 2012 and what is being discussed here.
But there are converses, since bereavement and non-genetically generated PTSD may not run the same course or length as major depression caused by some genetic tendency and a biochemical imbalance at large.
Its also happens to be a personal issue for me because I am trying to get back to a more stable state while my parents, who I am very close to, are still alive.I know it will be a tough thing that I don't really want to constantly remind myself even if it does creep in and is a major issue -- it doesn't serve a purpose since they are alive.
But I will be genetically predisposed to have a greater chance for major depression, I don't actually want to think about right now even though it always enters the mind.
Its not something I can prevent, nor can anyone prevent the transient unexplained and temporary nature that is life and the "Here and Now" or the unexpected things that can't be forseen.
-- tidings
Jay
Posted by Phillipa on December 6, 2008, at 12:40:02
In reply to Re: Bereavement Depression Treat Same As Major Deprssi, posted by yxibow on December 6, 2008, at 0:07:05
Jay I agree with you on above. Just wanted to add that I do feel for you. Things are very difficult now for you my heart feels your pain. Love Phillipa ps your knowledge is incredible. I do admire you.
Posted by bleauberry on December 6, 2008, at 18:08:35
In reply to Bereavement Depression Treat Same As Major Deprssi, posted by Phillipa on December 5, 2008, at 21:26:13
If the person does not have a history of psychiatric treatment, then I feel bereavement depression should be treated psychologically not biologically. Whether it is the loss of a loved one, loss of a career, loss of home, loss of money, loss of marriage, whatever...it has an identifiable cause. If you ask someone where their depression comes from and they say they don't know, that is biological in its roots. If they say they do know where it comes from, then that issue needs to be treated with a good counselor and church and psychotherapist so as to understand the whole process, what to do now, and where life should be a few months from now, and where life should be a few years from now. Just putting things into context and into the bigger picture can help a lot, but it often takes a professional to do that. Just talking with friends probably won't cut it.
Letting it go untreated though, allowing time by itself to do the healing, injects the possibility of the hormone/stress system to malfunction long enough that it turns into biological depression. That needs to be avoided with prompt treatment, but drugs should not be the first line of attack.
Just my opinions. No black or white. No right or wrong. Just how I feel. If you know where it comes from, get help. If you don't, get meds.
Posted by Phillipa on December 6, 2008, at 19:57:51
In reply to Re: Bereavement Depression Treat Same As Major Deprssi, posted by bleauberry on December 6, 2008, at 18:08:35
I know exactly where mine came from when thyroid went south. Before then just anxiety . So saying shouldn't have ever taken the paxil? Sick as a dog for over three months lopressor also. Think to doc wanted to substitute ad's for benzos. Was on such a low dose also. Ever hear of vertigo with thyroid issues as that it what tipped the scales about three months after being better on synthroid and xanax? Had already lowered xanax does. Then Merry go round began. Love Phillipa ps interesting answers.
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