Reply to V Code for Bereavement

Dr Corruble and Colleagues Reply

To the Editor: We thank Dr Clayton for her comment about our article.1 We particularly appreciate her synthetic clinical description, based on a large number of publications, of the relationship between bereavement and depressive symptoms over time. One of the questions raised by this literature is whether, when, and how bereaved people with depressive symptoms should be recognized and treated as having major depressive episodes (MDE).

Our results tend to show that the DSM-IV bereavement exclusion for MDE, instead of giving the ability to identify a self-limited "normal" depressive syndrome, may lead to the exclusion of individuals with symptoms of major depression that are more severe than those of typical MDE patients. Keeping the MDE bereavement exclusion criterion could indeed result in patients’ failing to be correctly diagnosed, living with prolonged and unnecessary suffering, and not getting appropriate treatment.

We think that our results could be interpreted in 2 different ways. A first hypothesis would be that the investigators of this study may have skipped the bereavement exclusion E criterion for MDE. However, the involved clinicians were specifically trained before the beginning of the study about the DSM MDE criteria and were asked, during the protocol, to check individually each DSM-IV MDE diagnosis criterion. Thus, this hypothesis might not be the most likely, although it would be difficult to rule out. The second hypothesis, which could be more relevant, is that the bereavement exclusion criterion may not be applicable in the real life of office-based clinical practice. Difficulties in applying this exclusion criterion might be due to its polythetic presentation, as it includes not only symptom cues, but also functional impairment and time period features.

Before modifying or deleting the bereavement exclusion E criterion for MDE is proposed, obtaining prospective data about the outcome of individuals excluded from the diagnosis of MDE due to the bereavement exclusion criterion would be useful. Whatever the outcome of the MDE bereavement exclusion criterion in the DSM-V (modification or deletion), we do agree with the proposition of Dr Clayton that the V code for bereavement should be maintained. The V code for bereavement and MDE bereavement exclusion criterion are 2 separate issues, but could complement each other in the direction suggested by Dr Clayton. This recommendation would be in agreement with our data and would contribute to solving the issue of the controversial MDE bereavement exclusion criterion.

Reference

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

Emmanuelle Corruble, MD, PhD

[email protected]

Philip A. P. M. Gorwood, MD, PhD

Guy Chouinard, MD, MSc Pharmacol

Author affiliations: INSERM U 669, Department of Psychiatry, Paris XI University, Bicêtre University Hospital, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre (Drs Corruble and Chouinard); INSERM U675, Paris VII University, Assistance Publique-Hôpitaux de Paris, Paris, France (Dr Gorwood); and Fernand-Seguin Research Centre, Hôpital Louis-H Lafontaine, Department of Psychiatry, University of Montreal, and Departments of Psychiatry and Medicine, Clinical Psychopharmacology McGill University Health Centre, Montreal, Quebec, Canada (Dr Chouinard). Potential conflicts of interest: Dr Corruble has received consulting fees and honoraria within the last 5 years from Wyeth, Lilly, Servier, Pfizer, Bristol-Myers Squibb, and Janssen-Cilag. Dr Gorwood has been a consultant for Eli Lilly and Bristol-Myers Squibb and has received honoraria from Servier, Janssen, Eli Lilly, and Bristol-Myers Squibb. Dr Chouinard has received consulting and advisory fees from Takeda. Funding/support: The study discussed in this letter was supported by research grants from Paris XI University, INSERM U669, and Servier. Servier had no involvement in the design, organization, analysis, or preparation for publication of the study.

doi:10.4088/JCP.09lr05646ablu

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