V Code for Bereavement
To the Editor: It is difficult to understand the conclusions of the recent article, "Is DSM-IV Bereavement Exclusion for Major Depressive Episode Relevant to Severity and Pattern of Symptoms? A Case-Control, Cross-Sectional Study."1 The authors found that those with a major depressive episode (MDE) excluded because of criterion BE, the bereavement exclusion criterion, were more severely depressed and that 2 symptom clues, suicidal ideation and worthlessness, were more pronounced in the bereavement-excluded individuals. They admit in the discussion that physicians failed to discriminate between individuals meeting all DSM-IV criteria except the bereavement E criterion (the BE group) and the MDE controls. What the study indicates, then, is that the French practitioners who participated in the national cross-sectional study to assess major depressive disorders did not apply the criteria listed in DSM-IV, especially the poorly worded criterion E.
Having studied more than 200 recently bereaved and following them prospectively, I conclude that the usual bereaved individual has many of the symptoms of major depression in the first months after a loss. These symptoms typically dissipate slowly over time, but even at their worst, most do not have suicidal thoughts, feelings of worthlessness, or self-deprecation, and they do not have psychomotor retardation. DSM-IV indicates that if after 2 months the bereaved have any of these symptoms, they should be considered to have major depression. It is not surprising that a bereaved person with major depression may have more symptoms than a depressed person without a significant stress such as bereavement. Bereaved individuals suffer; they feel sad, down in the dumps, depressed; and can’ t sleep or eat and may lose 40 pounds in the first months (although most reluctantly admit that they subsequently regained that weight). Their most lingering symptom is insomnia. For the most part, they do not seek psychiatric care.2-7
If the criteria are confusing and delegate people seeking treatment after bereavement to a V code, it may be that the instructions are poorly written and that criterion E for major depression should be deleted, but the V code should remain.
References
1. Corruble E, Chouinard VA, Letierce A, et al. Is DSM-IV bereavement exclusion for major depressive episode relevant to severity and pattern of symptoms? A case-control, cross-sectional study. J Clin Psychiatry. 2009;70(8):1091-1097. PubMed doi:10.4088/JCP.08m04475
2. Clayton PJ, Desmarais L, Winokur G. A study of normal bereavement. Am J Psychiatry. 1968;125(2):168-178. .PubMed
3. Clayton PJ, Halikas JA, Maurice WL. The depression of widowhood. Br J Psychiatry. 1972;120(554):71-77. PubMed doi:10.1192/bjp.120.554.71
4. Clayton PJ. Mortality and morbidity in the first year of widowhood. Arch Gen Psychiatry. 1974;30(6):747-750.
5. Clayton PJ, Herjanic M, Murphy GE, et al. Mourning and depression: their similarities and differences. Can Psychiatr Assoc J. 1974;19(3):309-312. PubMed
6. Clayton PJ, Darvish HS. Course of depressive symptoms following the stress of bereavement. In: Barrett J, ed. Stress and Mental Disorder. New York, NY: Raven Press; 1979.
7. Clayton PJ. Bereavement. In: Paykel ES, ed. Handbook of Affective Disorders. Edinburgh, Scotland: Churchill Livingstone; 1982.
Author affiliation: American Foundation for Suicide Prevention, New York, NY. Potential conflicts of interest: No financial/material support. Funding/support: None reported.
doi:10.4088/JCP.09lr05646blu
© Copyright 2010 Physicians Postgraduate Press, Inc.
