Douglas Berger Tokoyo Psychiatrist Responds to "Bereavement, Grief, and Depression: Clinical Update and Implications" article originally published on February 20, 2017 in "Psychiatric Times"
The logic of some key points of this article on complex bereavement (PCBD) has some serious problems, and I beg the senior author Dr. Bui of Harvard to reply.
In the “Persistent Complex Bereavement Disorder” section the authors state that PCBD, “has been shown to be distinct from mood, anxiety, and other trauma-related disorders despite some symptom overlap”.
Then later in that section they state that, “…risk factors for PCBD are similar to those for other bereavement-related conditions including MDD and PTSD, which suggests that all of these conditions share some common pathophysiologic processes.”
Two sections later under the “MDD” section they then say, “…recent studies have found no substantial differences between bereavement-related depressive syndromes and non-bereavement related depressive syndromes in terms of clinical characteristics and treatment response…”, and that, “The bereavement exclusion was dropped in DSM-5, and the death of a loved one no longer precludes the diagnosis of MDD…”.
They want to say that PCBD is distinct from MDD, but wait, they can have the same pathophysiology and the same clinical characteristics and treatment response (and we now can bill insurance companies for PCBD). This is strange medical science logic, unless billing has become part of medical science.
Even if there are some clinical and epidemiologic data suggesting some difference between PCBD and MDD, distinguishing psychiatric disorders that have SUBJECTIVE parameters as the endpoints of a study is in no way robust enough to say, “…it has been shown..” by any stretch of the imagination in these constructs that have similar pathophysiology and the same clinical characteristics and treatment response to be “distinct”.
To begin with, there are really no biologic anchor points to clearly objectify any psychiatric disorder from another in a population of patients and certainly there is no way to prove what an individual’s diagnostic label should be much less in these conditions the authors themselves note to be extremely similar. Diagnostic labels in psychiatry are really only road signs for the doctor and patient to use as a working model for treatment. These authors need more modesty and clarity of the financial upside of making DSM diagnoses.
Ok, a person in complicated grief can yearn intensely for the deceased, feel confusion about themselves, and be unable to trust others. Is this so different from the many persons' therapists see who are persistently depressed after any intimate breakup?
I recommend a review of this article in the PT
I think the logic presented by Allen Frances is the most lucid regarding avoiding over-medicalizing.
Next, the authors note that Complicated grief treatment (CGT) has “shown efficacy…across 3 randomized controlled trials”, all authored by Shear, however, none of these trials were single-blind (=subject blind), or double-blind (thus no blind placebo).
See the most recent trial here:
This study had a “placebo”, but the term is misleading as a psychotherapy can not have a blind placebo group.
Do these Harvard authors wish to opine that a therapeutic modality in conditions with subjective endpoints can be show efficacy without a double-blind and blind placebo controlled study? Blind raters only record what unblinded subjects report.
Regarding disclosures, Dr. Bui has also worked with Dr. Shear, the author of the Complicated grief treatment trials noted in references 9-11 in the PT article on this study, and Director of the “Center for Complicated Grief”. The therapists of which bill clients for grief therapy and charge fees for workshops up to $600 per attendee (https://www.eventbrite.com/e/level-2-complicated-grief-treatment-tickets-30468955466), so there is some motivation to have CGT show efficacy in a “clinical trial”.
Bui and Shear coauthors on:
THE STRUCTURED CLINICAL INTERVIEW FOR COMPLICATED GRIEF: RELIABILITY, VALIDITY, AND EXPLORATORY FACTOR ANALYSIS
In this article, while Bui notes “Although diagnostic criteria for CG have yet to be adequately validated, the SCI-CG may facilitate this process.” He then says, “The SCI-CG can now be used as a validated instrument in research and clinical practice.”
This means we can validate an instrument for a diagnosis where the diagnostic criteria are not validated?
This article requires rethinking, rewriting, and re-disclosing.
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Author - Douglas Burger
Bilingual Psychiatrist located in Tokyo.