The bereavement exclusion was formally eliminated in the spring of 2013, with the publication of DSM-5. The exclusion was a provision in earlier editions, that a “diagnosis of major depressive disorder” could not be assigned to a bereaved person, even though he or she met the criteria, unless certain additional considerations were met. The history of its elimination provides an interesting example of psychiatry’s relentless expansion of its net. The issues involved take us right to the heart of the psychiatric hoax.
THE NINE-ITEM CHECKLIST
In psychiatry, “major depression” is “diagnosed” essentially by the presence of five or more “symptoms” from a nine-item checklist. The checklist has endured with almost identical wording from DSM-III to DSM-5. In all of these editions, the checklist appears as criterion A. Here’s how it is worded in DSM-5:
“A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly attributable to another medical condition.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.” (P 160-161)
Criterion B is also noteworthy:
“B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.” (P 161)
It’s clear that the terms used in A and B are too vague to have any objective discriminatory value. How much of the day is “most of the day”? How many days a month is “nearly every day”? What hard-working person doesn’t experience some measure of fatigue or loss of energy nearly every day? How much guilt is excessive? How often is recurrent? Etc. And why is irritability in children considered a manifestation of depression? It is also particularly noteworthy that the “symptoms” need to have been present for only two weeks.
Criterion B, which purports to be an impact criterion, has no discriminatory value at all. The terms clinically significant, distress, and impairment are hopelessly subjective and prone to personal bias. What, for instance, does clinically significant impairment in social functioning mean? Does it mean that the individual has stopped socializing completely, or that he has begun to feel ill at ease in some social situations; or something in between?
It also needs to be pointed out that the selection of items is entirely arbitrary. There is no factual or logical reason for selecting these items or for requiring a minimum of five.
THE BEREAVEMENT EXCLUSION IN THE DSMs
There is no mention of bereavement or bereavement exclusion in either DSM-I (1952) or DSM-II (1968).
Here’s how the bereavement exclusion was worded in DSM-III (1980). It is item E on the criteria list for a “major depressive episode”:
“E. Not due to any Organic Mental Disorder or Uncomplicated Bereavement.” (p 214)
In other words, if the person’s sadness was due to an organic mental disorder or to uncomplicated bereavement, then it could not be considered a “major depressive episode” — this “diagnosis” was excluded.
Later in the text, uncomplicated bereavement is described as:
“V62.82 Uncomplicated Bereavement This category can be used when a focus of attention or treatment is a normal reaction to the death of a loved one (bereavement).
A full depressive syndrome frequently is a normal reaction to such a loss, with feelings of depression and such associated symptoms as poor appetite, weight loss, and insomnia. However, morbid preoccupation with worthlessness, prolonged and marked functional impairment, and marked psychomotor retardation are uncommon and suggest that the bereavement is complicated by the development of a Major Depression.” (p 333)
Earlier in the text, the distinction between uncomplicated bereavement and a “major depressive episode” is set out:
“Uncomplicated Bereavement is distinguished from a major depressive episode and is not considered a mental disorder even when associated with the full depressive syndrome (see p. 333). However, if bereavement is unduly severe or prolonged, the diagnosis may be changed to Major Depression.” (p 213)
From all of this, it’s clear that the bereavement exclusion in DSM-III was not considered by the APA as a total ban on assigning a bereaved person a “diagnosis of major depression,” but interestingly, it was so considered by many psychiatrists. This is probably because the wording in the criteria list was straightforward: “Not due to . . . Uncomplicated Bereavement.” But the easements on the ban were set out elsewhere in the text, and most psychiatrists, then and now, read only the criteria lists. So a great many bereaved people were escaping the psychiatric net, a situation that was “remedied” in 1987, with the publication of DSM-III-R. In that edition the easements on the ban were included in the criterion item:
“B (2) The disturbance is not a normal reaction to the death of a loved one (Uncomplicated Bereavement).
Note: Morbid preoccupation with worthlessness, suicidal ideation, marked functional impairment or psychomotor retardation, or prolonged duration suggest bereavement complicated by Major Depression.” (p 223)
So, a bereaved person who met five or more of the nine checklist items for major depression could be given that “diagnosis” if at least one of the easements was also present. At that time, prolonged duration was generally interpreted as more than two years. It should also be noted that there is considerable overlap between the easements and the checklist items, so in many cases, no additional “symptoms” were needed.
But more importantly, the inclusion of the easements in the criteria list served as a reminder to psychiatrists that the bereavement exclusion was not a total ban, and it is reasonable to assume that this led to more bereaved people being enrolled by psychiatry. Bereavement, after all, is an ideal opportunity for a psychiatrist to acquire a client. The individual is likely to be emotionally devastated, vulnerable, receptive to offers of help, and compromised at least somewhat in judgment. So the psychiatrists pushed their phony diagnoses and their “safe and effective” remedies, and business continued to grow.
In 1994, the APA published DSM-IV, which was drafted under the chairmanship of Allen Frances, MD. The bereavement exclusion item for “major depressive episode” reads:
“E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.” (p 327) [Emphasis added]
Note that the easements have been inserted into the criterion, as opposed to an addended note, and that the term “prolonged duration” from DSM-III-R has been changed to “longer than two months.” Note also, as in DSM-III, the use of the word “or,” indicating that only one of the easements is required in addition to five of the nine checklist items. So, given that a psychiatrist interviewing a bereaved person is likely to find five yeses on the checklist, grieving for a loved one beyond two months, or the presence of any of the easements listed in the above quote, is sufficient additional information to warrant a “diagnosis of major depressive disorder,” which is, according to psychiatrists, an illness, just like diabetes, requiring psychiatry’s so-called safe and effective treatments, i.e. neurotoxic drugs and high voltage electric shocks to the brain.
And it is worth remembering that Allen Frances, MD, the architect of this travesty, continues to this day to blame general practitioners for the exponential expansion of psychiatric drugging in our society over the past two decades. Allen Frances, MD, who made it absolutely clear in DSM-IV that a bereaved person who meets five or more of the nine items on the facile checklist, and has been grieving for more than two months, can be given a “diagnosis” of “major depressive disorder”; enrolled as a psychiatric “patient”; and, of course, prescribed psychiatric drugs.
And now, since DSM-5 (2013), even Dr. Frances’s two month exclusion period is gone. The bereavement criterion item is also gone. All that remains is the following note inserted between criterion C and criterion D:
“Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss.” (p 161)
Note that bereavement is no longer afforded special consideration, but is rolled in with other kinds of losses.
Note also that even though the person’s sadness might be “understandable” or “appropriate,” “the presence of a major depressive episode . . . should also be carefully considered.” And, of course, such a decision “requires the exercise of clinical judgment.” This is particularly relevant in that the only way that “the presence of a major depressive episode” can be “carefully considered” is by comparing the individual’s presentation against the superficial, inherently subjective nine-item checklist. In this regard, there are enormous incentives for a psychiatrist to “make the diagnosis”, and none at all for declining to do so.
Interestingly, DSM-5 also provides a footnote to help psychiatrists make this judgment. Here it is:
“In distinguishing grief from a major depressive episode (MDE), it is useful to consider that in grief the predominant affect is feelings of emptiness and loss, while in MDE it is persistent depressed mood and the inability to anticipate happiness or pleasure. The dysphoria in grief is likely to decrease in intensity over days to weeks and occurs in waves, the so-called pangs of grief. These waves tend to be associated with thoughts or reminders of the deceased. The depressed mood of MDE is more persistent and not tied to specific thoughts or preoccupations. The pain of grief may be accompanied by positive emotions and humor that are uncharacteristic of the pervasive unhappiness and misery characteristic of MDE. The thought content associated with grief generally features a preoccupation with thoughts and memories of the deceased, rather than the self-critical or pessimistic ruminations seen in MDE. In grief, self-esteem is generally preserved, whereas in MDE feelings of worthlessness and self-loathing are common. If self-derogatory ideation is present in grief, it typically involves perceived failings vis-à-vis the deceased (e.g., not visiting frequently enough, not telling the deceased how much he or she was loved). If a bereaved individual thinks about death and dying, such thoughts are generally focused on the deceased and possibly about ‘joining’ the deceased, whereas in MDE such thoughts are focused on ending one’s own life because of feeling worthless, undeserving of life, or unable to cope with the pain of depression.” (p 161)
No references are provided to substantiate any of these discriminant assertions, but even if references were provided, the assertions, like almost everything else in the DSM, are too vague to be definitive. How, for instance, can we distinguish “feelings of emptiness and loss” from “the inability to anticipate happiness or pleasure”? What questions could one put to a grieving person that would help clarify this matter? Could any of us even draw such distinctions in ourselves if we were feeling sad or despondent?
Later in the DSM-5 text, the APA provides the rationale for eliminating the two month exclusion, which as we saw earlier, wasn’t really an exclusion at all.
“In DSM-IV, there was an exclusion criterion for a major depressive episode that was applied to depressive symptoms lasting less than two months following the death of a loved one (i.e., the bereavement exclusion). This exclusion is omitted in DSM-5 for several reasons, including the recognition that bereavement is a severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual, generally beginning soon after the loss, and can add an additional risk for suffering, feelings of worthlessness, suicidal ideation, poorer medical health, and worse interpersonal and work functioning. It was critical to remove the implication that bereavement typically lasts only 2 months, when both physicians and grief counselors recognize that the duration is more commonly 1-2 years. A detailed footnote has replaced the more simplistic DSM-IV exclusion to aid clinicians in making the critical distinction between the symptoms characteristic of bereavement and those of a major depressive disorder.” (p 811)
Note the hypocrisy: “It was critical to remove the implication that bereavement typically lasts only 2 months,” when in reality the DSM-5 work group reduced this period to zero!
Since the publication of DSM-5, a psychiatrist is under no onus, formal or informal, to observe any waiting period at all before “diagnosing” a bereaved person with “major depressive disorder,” enrolling him or her as a “patient,” and prescribing psychiatric drugs. All that he or she has to do is note five or more hits on the checklist.
. . . . . . . . . . . . . . . .
As mentioned earlier, the bereavement exclusion was never a total ban, and even under DSM-III, any moderately creative psychiatrist could have used the inherently vague criteria to circumvent the exclusion. Obviously, the elimination of the exclusion did widen the psychiatric net somewhat, but probably not hugely. So the question naturally arises: why did the APA bother with this endeavor at all? And to address this question, we have to take a brief historical detour.
BRIEF HISTORY OF THE DSM
DSM-I was published in 1952, and, from the perspective of present-day psychiatry, made one enormous error: it acknowledged prominently and unambiguously that most of the so-called mental disorders are “of psychogenic origin.” The manual divided “mental disorders” into two main categories: those resulting from brain damage/malfunction (e.g., infections, trauma, alcohol poisoning, etc.) and those “of psychogenic origin,” which are “the result of a more general difficulty in adaptation of the individual…” (p 9). The latter group included: “manic depressive reactions”; “psychotic depressive reactions”; “schizophrenic reactions”; “paranoid reactions”; “anxiety reaction”; “dissociative reaction”; “obsessive compulsive reaction”; “depressive reaction”; etc.
The implications of the word “reaction” in the names of the “disorders,” as in the examples given above, were not formally discussed in DSM-I, but were acknowledged 28 years later, in DSM-III.
“The use of the term ‘reaction’ throughout the classification reflected the influence of Adolf Meyer’s psychobiological view that mental disorders represented reactions of the personality to psychological, social, and biological factors.” (p 1)
So, in DSM-I there was no suggestion of chemical imbalances or illnesses-just-like-diabetes. The “disorders” were conceptualized as reactions of the personality, and were clearly recognized as being “of psychogenic origin.”
And lest there be any doubt as to the intentions of the authors, many of the textual descriptions in DSM-I embody exclusively psychological explanations. For instance:
“…a psychotic reaction may be defined as one in which the personality, in its struggle for adjustment to internal and external stresses, utilizes severe affective disturbance, profound autism and withdrawal from reality, and/or formation of delusions or hallucinations.” (p 12)
“…a psychoneurotic reaction may be defined as one in which the personality, in its struggle for adjustment to internal and external stresses, utilizes the mechanisms listed above to handle the anxiety created.” (p 13)
The emphasis on psychological explanations was not merely a reflection of Adolf Meyer’s influence, but a reflection of the fact that a great many psychiatrists at that time (1952) subscribed to this position and were entirely comfortable with these types of psychoanalytic explanations. But at the same time, it did generate some dissonance. Problems “of psychogenic origin” are clearly not illnesses in any ordinary sense of the term, but, as qualified physicians, psychiatrists felt that they should be treating illnesses. They resolved this dissonance, individually and collectively, by calling the problems illnesses and referring to their customers as mentally ill, while continuing to “treat” these problems through supportive discussion and “talk therapy.” The ruse didn’t really fool anybody, least of all themselves, and psychiatrists were routinely derided by other physicians because of the non-medical nature of their subject matter and their “cures.”
The definitive history of these times hasn’t yet been written, but it is reasonable to suppose that the formal codification of the psychogenic position in psychiatry’s official diagnostic manual exacerbated these negative evaluations. But against all this, psychiatrists at that time were a confident and sturdy bunch, and probably could have weathered the external derision and the internal dissonance reasonably well, if the drugs hadn’t started to become available.
The first neuroleptics and anti-depressants were developed in the 50’s, and psychiatrists, even those who weren’t entirely happy about prescribing drugs (and there were many), recognized that they offered a path to prima facie medical legitimacy, the ability to carry much bigger caseloads, and a commensurate increase in remuneration. No longer would it be necessary to delve collaboratively and time-consumingly into a client’s childhood conflicts, current fears, or counter-productive relationships. All that was needed was a label that posed as a diagnosis; a 15-minute med check; a hastily-written prescription; out you go; next please; and “look at me, Ma, I’m a real doctor.”
But obstructing the gates to this psychiatric Eden was DSM-I: a kind of psychiatric conscience, unambiguously insisting that the problems in question weren’t illnesses at all, and mocking the notion of “treating” these non-illnesses with tranquilizers and happy-pills. And as the 50’s gave way to the 60’s, and more drugs came on-stream, it became increasingly clear that the psychogenic framework of DSM-I had to go.
But it couldn’t be just obliterated out of hand. This would attract too much negative attention, and besides, psychiatry didn’t have a biological pathology framework to put in its place. So the decision was made, and it was truly a piece of propaganda genius, that DSM-II (1968) would systematically ignore the question of cause. Watch how the wording tip-toed around the central issue:
“In selecting suitable diagnostic terms for each rubric, the Committee has chosen terms which it thought would facilitate maximum communication within the profession and reduce confusion and ambiguity to a minimum.” (DSM-II, p viii)
Notice, there’s no mention of eliminating causal language. There’s no mention of the fact that the entire foundation of DSM-I is being scrapped. They just want to keep confusion and subjectivity to a minimum!
“The Committee accepted the fact that different names for the same thing imply different attitudes and concepts. It has, however, tried to avoid terms which carry with them implications regarding either the nature of a disorder or its causes…” (DSM-II, p viii)
This is the first acknowledgement of the intention to make the system cause-neutral. What’s particularly interesting here is that in real medicine, cause is integral to the concept of diagnosis. The then-current Taber’s Medical Dictionary (1968 edition) defines the verb diagnose as: “to determine the cause and nature of a pathological condition.” Yet here’s the APA systematically eliminating causal language from their so-called diagnostic manual.This makes no sense unless seen against the enormous “blunder” of DSM-I.
“In the case of diagnostic categories about which there is current controversy concerning the disorder’s nature or cause, the Committee has attempted to select terms which it thought would least bind the judgment of the user. (p viii)
In other words, eliminate references to causes.
“Consider, for example, the mental disorder labeled in this Manual as ‘schizophrenia,’ which, in the first edition, was labeled ‘schizophrenic reaction.’ The change of label has not changed the nature of the disorder, nor will it discourage continuing debate about its nature or causes. Even if it had tried, the Committee could not establish agreement about what this disorder is; it could only agree on what to call it.” (p xi)
Note how the cause-neutral decision is being presented as benign and largely insignificant. In reality, the change from “schizophrenic-reaction” of psychogenic origin to “schizophrenia” had enormous implications. It very definitely discouraged debate about its origin and causes, and paved the way for the avidly-promoted chemical imbalance theory that dominates psychiatry to this day.
And so in DSM-II, schizophrenic reaction became schizophrenia; manic-depressive reaction became manic depressive illness; anxiety reaction became anxiety neurosis; obsessive-compulsive reaction became obsessive compulsive neurosis; phobic reaction became phobic neurosis; etc. In addition, almost all of the explanatory language was removed from the descriptive text.
This process was continued twelve years later in DSM-III (1980), and was completed in DSM-III-R (1987) under the leadership of psychiatrist Robert Spitzer, MD. And incidentally, Dr. Spitzer also played a key role in DSM-II. Here’s an interesting quote from DSM-II’s foreword:
“Throughout, the Committee has had the good fortune to have as consultant . . . Dr. Robert L. Spitzer . . . Dr. Robert L. Spitzer, Director, Evaluation Unit, Biometrics Research, New York State Psychiatric Institute, served as Technical Consultant to the Committee and contributed importantly to the articulation of Committee consensus as it proceeded from one draft formulation to the next.” (p ix-x)
So the eminent Dr. Spitzer, remembered today as the architect of DSM-III, was responsible for the “articulation of Committee consensus” in DSM-II. And we can see clearly where the drafting was headed: cause-neutrality, i.e., regardless of why a person is despondent, if he scores five or more yeses on the checklist, he has major depression, the “illness,” and therefore needs medical treatment. The notion that one can gain an understanding of a person’s sadness by ignoring its causes and contexts, and simply bumping his superficial presentation against a fabricated checklist, and seeing if he scores hits on at least five, is simply inane. It’s like trying to understand a poem by counting the words. Anyone with the slightest compassion or understanding of human experience can see this. Even psychiatrists in the 70’s could see it, and at the time, many demurred. But so desperate were they for even the appearance of legitimate medical status that the vast majority ultimately embraced the hoax, and in the decades since, have devoted themselves unstintingly to the task of selling it to their customers, the public, the media, legislators, the judiciary, parents, school teachers, real doctors, new psychiatric recruits — and anyone else who will listen.
Also, as mentioned earlier, the drugs were coming on-line fast, and psychiatrists were highly motivated to climb onto that particular gravy train. But, at least here in the US, one is not permitted to prescribe a drug without specifying the illness that the drug purports to treat. So, the entirely unfounded biological-pathology-model of earlier decades was dusted off, expanded, and re-presented as the “atheoretical” or “cause-neutral” model of the 80’s, and has driven psychiatry to the dizzying heights of prestige and financial success that it now enjoys. But as high as psychiatry has soared in status and commercial success, it has descended as deeply in venality and deception. The causes that were systematically dismissed from consideration in the drive towards cause-neutrality were the psycho-socio-economic causes. The causes that were left in were the non-existent biological pathology causes: the spurious chemical imbalances and neural circuitry anomalies that are still being sold to psychiatry’s customers to this day.
As formulated by Robert Spitzer and his DSM-III work group, the bereavement exclusion, though by no means complete, did represent a tiny islet of reality and decency in this status-seeking, money-grubbing, pharma-psychiatric ocean of deceptive, self-serving drug-pushing. By 1994, with the publication of Allen Frances’s DSM-IV, it was gone in all but name.
And so, I suppose, we shouldn’t be too surprised to learn that Dr. Frances himself, and members of the Mood Disorder Work Group, had significant financial links to the pharmaceutical industry. Dr. Frances had a very remunerative link to Johnson & Johnson in which he and two colleagues were paid handsomely for promoting Johnson & Johnson’s neuroleptic drug Risperdal. The entire sordid story is laid out in Paula Caplan’s article Diagnosisgate: Conflict of Interest at the Top of the Psychiatric Apparatus.
With regards to the Mood Disorders Work Group, in 2006, Lisa Cosgrove, PhD, et al published “Financial Ties between DSM-IV Panel Members and the Pharmaceutical Industry.” Here’s a quote:
“Of the 170 DSM panel members 95 (56%) had one or more financial associations with companies in the pharmaceutical industry. One hundred percent of the members of the panels on ‘Mood Disorders’ and ‘Schizophrenia and Other Psychotic Disorders’ had financial ties to drug companies.” [Emphasis added]
So all of the DSM-IV “Mood Disorders” work group members — i.e. the members who were involved in the gutting of the bereavement exclusion — had financial ties to drug companies.
. . . . . . . . . . . . . . . .
With the publication of DSM-5 in 2013, not even a trace of the bereavement exclusion remained. The bogus cause-neutral perspective (in reality the bogus biological-pathology perspective) was now the de facto psychiatric position, with no exceptions.
So, to recap, the bereavement exclusion was included by Robert Spitzer and the APA in DSM-III (1980). We don’t know why this was done. Perhaps at that time it seemed too inane to tell bereaved individuals that their sadness and despondency were caused by an illness! In any event, it was included, and, presumably, saved some people from the soul-grinding mill of psychiatric “care.” And that, of course, posed a problem for psychiatrists, whose primary objective is to make the dubious benefits of their professional endeavors available to all.
But the much more serious problem for psychiatry was that if the so-called cause-neutral stance could be suspended for bereavement, then it could also be suspended for other major losses: such as becoming severely disabled; having a spouse or child become severely disabled; losing one’s home to a flood; losing one’s life savings to a scam; etc. These kinds of catastrophic events are the primary gateways into the psychiatric net. So the bereavement exclusion had to go. Dr. Frances killed it in 1994, and David Kupfer, MD, Chairperson of DSM-5, officiated at the burial in 2013.
BUT THE BEREAVEMENT EXCLUSION DIDN’T DIE OF NATURAL CAUSES
In between the various salient junctures, a great deal of psychiatric effort was being expended, the purpose of which was to demonstrate that distinguishing between bereavement-related depression (the non-illness), and “depression-the-illness” was invalid in principle, and unhelpful in practice. Over the years several studies, as well as commentaries about the studies, appeared in the psychiatric literature.
The very eminent and scholarly psychiatrist, Ronald Pies, MD, was particularly active in this area. Between 2008 and 2015, he authored or co-authored at least fifteen papers on this general topic. In 2009, for instance, he published Depression and the pitfalls of causality: Implications for DSM-V, in the Journal of Affective Disorders. Here’s the abstract:
“Causal narratives are often invoked as explanations for depressive episodes, and some have argued that even serious depressive symptoms in the context of recent bereavement should not be considered a psychiatric disorder. However, the limited data we have suggest that ‘bereavement-related depression’ does not significantly differ from non-bereavement-related major depression, in terms of symptom picture, risk of recurrence, or clinical outcome. Furthermore, the notion of establishing a psychosocial precipitant (such as loss of a loved one) as the ’cause’ of a patient’s depression fails to consider several confounding variables. The patient may have an inaccurate or distorted recollection of depression onset, or be unaware of pre-existing medical and neurological conditions that are strongly ‘driving’ the depression. Moreover, judgments regarding how ‘proportionate’ or ‘disproportionate’ a person’s depressive symptoms are in relation to a putative ‘precipitant’ are fraught with uncertainties and may be influenced by cultural biases. Until we have controlled, longitudinal data showing that ‘bereavement-related depression’ differs significantly from non-bereavement-related major depression, it is premature and risky to alter our current ’cause-neutral’ diagnostic framework. Indeed, there are compelling reasons to eliminate the so-called bereavement exclusion from DSM-V.”
Well there’s not much doubt as to the venerable Dr. Pies’ objective here, but let’s take a look at the arguments he adduces in the article in support of these conclusions.
“…critics believe that by failing to examine ‘the context’ of depressive symptoms — for example, whether or not the patient has experienced recent bereavement — we are doing our patients a disservice (Horowitz and Wakefield, 2007) . . . But while this approach may usefully focus our attention on specific issues to explore in psychotherapy, it may also mislead us. For example, the depressed patient’s temporal reconstruction of cause and effect may be shaped by unconscious needs or rationalizations. The man who insists, ‘I got depressed because my girlfriend dumped me!’ may have been clinically depressed before the break-up, perhaps even precipitating the breach by his emotional withdrawal.”
And how would a psychiatrist establish that the client is “clinically depressed”? There is only one way — by comparing his presentation with the nine-item checklist, which relies almost entirely on self-report. So, the diligent psychiatrist should be skeptical of the “patient’s” explanation for his sadness (which might be “shaped by unconscious needs or rationalizations”), but should routinely accept as credible his reports on matters that confirm five or more hits on the checklist. This strikes me as a little arbitrary, but when we remember that the primary objective of the psychiatric interview is to confirm the “diagnosis,” it becomes perfectly understandable. It is also interesting that Dr. Pies affords no recognition to the reality that the psychiatrist’s perceptions and conclusions might also be shaped by unconscious, or indeed conscious, needs of his or her own, e.g. to make a living.
“To be sure, there is a tradition of ’cause-based’ diagnosis of depression, such as the now discredited distinction between ‘reactive’ and ‘endogenous’ depression. This dichotomy was abandoned largely because (a) factor-analytic and cluster analyses failed to show that ‘reactive’ depression separated adequately from so-called ‘endogenous’ depression; (b) the ‘reactive’ vs. ‘endogenous’ distinction did not show stability over time; and (c) the distinction did not help us predict the patient’s longitudinal course, suicide risk, or response to antidepressants (Furukawa et al., 1999; Oquendo et al., 2004; Akiskal et al., 1978). Similarly, to my knowledge, there are no well-controlled prospective studies showing that distinguishing full-blown major depressive symptoms ‘with cause’ from identical symptoms ‘without cause’ has important prognostic or treatment implications. This applies specifically to cases in which full criteria for major depression are met, within 2 months or so after the death of a loved one.”
So let’s consider two hypothetical cases: a man who is sad because his wife of fifty years has just died, and another man who is sad because his life has degenerated into a kind of treadmill existence that holds no meaning. Both men go to see a psychiatrist, who asks each: why are you depressed? The first person replies that his wife has recently died, and the psychiatrist makes a note of this on his pad. The second person shrugs and spreads his hands, unable to articulate a specific factor that has caused him to be sad. The psychiatrist, with one eye on the clock, notes on his pad: “no cause.” And this phenomenon, played out in psychiatric practices for decades, is the sole basis for psychiatry’s distinction of depression “with cause” from depression “without cause.”
In reality, “depression without cause” is depression in which the psychiatrist, for whatever reason, has not managed to ascertain the cause. Perhaps the psychiatrist is in too much of a hurry; or hasn’t taken pains to listen; or hasn’t established a basis for trust; or, because of his/her training, has assimilated the spurious notion that the cause doesn’t matter (cause-neutral). In any event, to assume, on the basis of psychiatry’s notoriously rushed assessments, that a person’s sadness is without cause strikes me as unwarranted and arrogant. Apart from those very few cases in which a general medical condition has precipitated feelings of depression, there’s always a psycho/socio/economic cause or causes underlying and maintaining the feelings of sadness. The cause is usually a loss, a disappointment, or abiding adverse circumstances. These can be relatively straightforward and clear (e.g., I live in a slum; I lost my job; my babies are growing up, etc.) or vague and diffuse (e.g., I just feel kind of lost; life is passing me by; my dreams have died; it all seems pointless somehow; etc.). In a context of trust and unhurried, unconditional respect, however, people can almost always articulate these matters in ways that make perfect sense. The primary requirement is that the listener must have no agenda of his/her own other than providing a safe and supportive space in which the individual can “think aloud,” and identify and articulate the source of the sadness. And the great problem with the psychiatric interview is that the psychiatrist always has an agenda; and that agenda is to nail down the “diagnosis.” Daniel Carlat, MD, then a Tufts Medical School professor of psychiatry, stated in a 2010 interview on NPR:
“We are in the business of making diagnoses using the DSM . . . We make our diagnoses, and then we usually prescribe medications.”
Psychiatrists who don’t nail down diagnoses go out of business. And “diagnoses” are almost always what they find. And they don’t find psycho-socio-economic causes, because they have been told that they’re not relevant. All that’s needed is five yeses on the facile checklist. So the client, who needs to talk about his sense of futility or his grief, or his loneliness, or the blighting of his dreams, is brought back “on track” with puerile questions about his appetite, his sleep, his energy level, etc. He answers as best he can, while the psychiatrist ticks off the yeses on the checklist. And — abracadabra — the hapless individual is diagnosed with “major depressive disorder,” a so-called life-threatening illness for which he is prescribed drugs and/or electric shocks to the brain. But the source or cause of the sadness remains unaddressed and, not surprisingly, continues to be: a source of sadness, masked somewhat by the daily ingestion of happy pills, but still a source of sadness.
And the reason that the psychiatrist is asking these inane questions is because Dr. Spitzer and his APA colleagues arbitrarily pulled them out of the hat thirty-seven years ago and embedded them into the DSM, where they shape psychiatric practice to this day.
. . . . . . . . . . . . . . . .
Dr. Pies assures us that factor and cluster analyses have failed to show that depression with cause differs substantially from depression without cause, and cites some studies to support this contention. Of course, as we all know, failure to find a difference doesn’t mean that there is no difference. But let’s set that aside, because there is a much more fundamental flaw in Dr. Pies’s reasoning. The flaw resides in the fact that the studies he cites conceptualize depression along psychiatric lines, i.e. as defined by five or more yeses on the nine-item checklist. Let’s also set aside the vagueness problem, and concede, for the sake of discussion, that the two hypothetical individuals described earlier have almost identical presentations on all nine items. They are each despondent nearly every day, for most of the day; they each report markedly diminished interest or pleasure in most activities, most of the day, nearly every day; they’ve each lost about 5% of body weight in the last month; and so on for the remaining items. And — critically for psychiatry — they each score five yeses, three noes, and one maybe. So, according to psychiatry, they each have the same illness: “major depressive disorder.”
But — and this is the critical point — this in no way establishes that the negative feelings stemming from the first individual’s bereavement are essentially the same kind of thing as the negative feelings stemming from the second individual’s abiding sense of futility. Nor would it establish that the individuals in question would benefit from the same kind of help, or even that they need help at all. The depth, meaning, essence, and variety of human emotions simply cannot be adequately conceptualized as binary scores on a nine-item facile checklist. Yet the very foundation of modern psychiatry rests on the assumption that they can. The “illness” that they call “major depressive disorder” consists of nothing more than five out of nine yeses on the checklist. And the checklist is just a psychiatric invention. It is emphatically not something that was discovered in nature. They just made it up! In fact, this was explicitly acknowledged by Dr. Spitzer in DSM-III (1980).
“It should be understood, however, that for most of the categories the diagnostic criteria are based on clinical judgment, and have not yet been fully validated by data about such important correlates as clinical course, outcome, family history, and treatment response.” (p 8)
And they certainly weren’t validated against biological pathologies. The admission was repeated verbatim in DSM-III-R (p xxiv).
The research that Dr. Pies cites in support of his contention can be summarized as follows: If a researcher in his/her work systematically ignores the psycho-socio-economic causes of depression, he/she will “discover” that the psycho-socio-economic causes have no relevance or importance. The researcher that uses only a camera to detect sound is likely to conclude that sound doesn’t exist.
. . . . . . . . . . . . . . . .
“The global ‘symptom profile’ of depressed individuals and their risk for depressive recurrence was similar in bereaved and non-bereaved subjects.”
The “global symptom profile,” of course, is five or more yeses on the nine-item checklist, and there is nothing in the checklist that would detect differences between these groups. It is also important to stress that bereaved individuals do not constitute a homogenous group, even with respect to the sadness and sense of loss. When the love between the deceased and the bereaved was profound, the sadness is usually equally profound. But when the love is commingled with negative feelings, the sadness is usually commensurately mitigated. So research findings about “bereaved subjects,” in which no account is taken of the depth of the loss, or indeed, other individualizing factors, are inevitably fraught with interpretation problems.
. . . . . . . . . . . . . . . .
“But we have no credible data showing that recent bereavement per se somehow ‘immunizes’ the patient who otherwise meets full symptomatic and duration criteria for major depression, thereby predicting a benign long-term course.”
Nor do psychiatrists have any credible data showing that individuals who meet five of the nine inherently vague and unreliable DSM criteria (i.e., “meet full symptomatic and duration criteria”) have an illness. But that doesn’t deter the vast majority of psychiatrists, including the eminent Dr. Pies, from routinely asserting otherwise.
. . . . . . . . . . . . . . . .
“Indeed, this unfounded notion may discourage some severely depressed, bereaved individuals from seeking professional help.”
And there it is — the sharp kernel of truth buried in the dense thicket of psychiatric obfuscation: the bereavement exclusion was bad for business!
Dr. Pies concludes his “…pitfalls of causality…” essay with this:
“Yes, we should search diligently for the causes of our patient’s depression. But ill-conceived diagnostic schemes that ignore the full range of data on bereavement-related depression are a disservice to our patients.”
And for once, apart from his unwarranted use of the term “patient,” I find myself in complete agreement with the most eminent and scholarly Dr. Pies. There has never been a more ill-conceived diagnostic scheme than that embodied in psychiatry’s Diagnostic and Statistical Manual, and it certainly constitutes a disservice to psychiatry’s customers.
Earlier, I mentioned that Robert Spitzer, MD, architect of DSM-III and DSM-III-R had played a key role in the drafting of DSM-II. It is also, I think, noteworthy that Allen Frances, MD, architect of DSM-IV, was a member of the personality disorders committee for DSM-III, and of the steering work group for DSM-III-R. And, David Kupfer, MD, architect of DSM-5, was a member of the steering work group for DSM-III-R and DSM-IV.
So it’s clear that there was a great deal of continuity built into the revision process from DSM-II to DSM-5. It is also clear that there was throughout this process a marked “cause-neutral” agenda, the purpose of which was to systematically eliminate the notion that psychiatry’s so-called mental disorders could arise from psycho-socio-economic issues, and to tacitly leave open the notion that they arose from biological pathologies, and were therefore amenable to “treatment” with drugs and electric shocks to the brain.
So when we members of the anti-psychiatry movement undermine this agenda by pointing out its glaring flaws and rampant destructiveness, we are upsetting an apple-cart that has been sixty years in the making. Sixty painstaking years. Sixty years of systematic deception. Sixty years of fraudulent research. Sixty years of inane checklists masquerading as diagnoses. Sixty years of destructive drugging and electric shocks. Sixty years of parroting slogans such as “safe and effective” and “the benefits outweigh the costs.”
And they almost succeeded in selling the hoax. The prize of acceptance and perceived legitimacy was almost gained, when the anti-psychiatry movement — “rabid ideologues” as Jeffrey Lieberman, MD, has called us — exposed the hoax, and sent six decades of carefully orchestrated deception and self-promotion down the maelstrom of dashed hopes.
Psychiatry is coming apart at the seams, and they have no response other than the repetition of their dogmatic assertions and the beration of their critics.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
Well, you do have a bunch of dealers looking everywhere for new markets for selling their addictive products.
How true. And markets they find.
Correction, Phil. “And markets they *CREATE*!…..
Thanks again, my friend!
Great blog, Philip, as always. Thank you.
I agree this is what is so insane about today’s DSM believing psychological and psychiatric practitioners’ theology, “It is also clear that there was throughout this process a marked ’cause-neutral’ agenda, the purpose of which was to systematically eliminate the notion that psychiatry’s so-called mental disorders could arise from psycho-socio-economic issues, and to tacitly leave open the notion that they arose from biological pathologies, and were therefore amenable to ‘treatment’ with drugs and electric shocks to the brain.”
My psychologist had to say I did not need her services within six months because she couldn’t answer the etiology question, and I was quite certain the etiology of my illness was the drugs she and other doctors coerced and forced upon me. Although, of course, all doctors adamantly denied this as a possibility.
But, of course, all the doctors were wrong. The antidepressants/”safe smoking cessation meds” create symptoms that appear to the “mental health professionals” to be the “bipolar” symptoms. And the DSM recommended “bipolar” treatments, combining the antidepressants and/or antipsychotics (aka neuroleptics), can create symptoms that appear to the “mental health professionals” to be both the negative and positive symptoms of “schizophrenia.” But the actual etiology of these symptoms are neuroleptic induced deficit syndrome and antidepressant or antipsychotic induced anticholinergic toxidrome.
What this means is today’s DSM is a classification system of the iatrogenic illnesses that can be created with the psychiatric drugs, as opposed to being a classification system of real “mental illnesses” with a “genetic” etiology, as the psychiatric industry has mistakenly assumed for the past 60 years.
But what’s great about this reality is that we could rid humanity of almost all the “mental illnesses,” if we could just get the psychiatrists and mainstream doctors to stop creating “mental illnesses” in people with their psychiatric drugs.
Yes. And, of course, under the cause-neutral umbrella, these kinds of causes are seldom even considered.
I quit desiring to kill myself by realizing I was not a monster, inherently inferior and unworthy of life.
How? By deciding psychiatrists were full of it and their “diagnoses” were a bunch of lying insults.
Agnosognosia saved my life! I plan on making t-shirts that say that for the next Psych Survivors rally. Like how the Brits played “Yankee Doodle Dandy” to insult the Colonial fighters. After soundly beating the British, the Colonists left the field playing “Yankee Doodle Dandy” as a song of triumph.
Ironic, isn’t it? You get all these people claiming there aren’t enough psychiatrists, especially in rural areas, and yet this is a “need” psychiatrists have manufactured for some time. All these “disorders” in the DSM, for instance, increasing the demand for psychiatrists. Every DSM that has come out, quite consciously it would seem, has increased the numbers of mental patients in the world by lowering the criteria for diagnosis. Think about it, and the world’s necessity for training more and more psychiatrists could decrease correspondingly. Seriously. Do we really need more failed MDs playing doctor as psychiatrist?
Too many junkies and not enough dealers!
Yes. Childhood disobedience is a “mental illness” (oppositional defiant disorder). Crime is a “mental illness” (conduct disorder), etc. Problems that previous generations dealt with now require specialized medical care! Who benefits?
Conduct used to be a mark on a report card. Now, in order to placate teachers, it and its corollaries, for disciplinary reasons, ODD, ADHD, etc., education has become an even more treacherous environment for students to navigate (if easier for teachers and other authoritarians). Psychiatry and psychology have entered the school systems as instruments of oppressive control and privacy invasion (not to mention corporate imperialism).
Eliminating the “bereavement exclusion” is just another method for psychiatrists to gain more patients, and thus more control and power, coupled with a deceptive sense of self-importance. Each DSM in succession has made for more ease in diagnosis. Many of us have been waiting a long time for this house of cards to tumble. Question is, how many more cards can it hold before people begin to get it!
Great blog, BTW. Keep up the good work!
Maybe this is not quite on topic but…
Phil, do you think you could write an article for those at risk for being given “depression screenings” with info on a) How to know if you’re being surreptitiously “screened” when you visit a physician; and b) What the “correct” answers to the questions are (assuming one wants to “pass”)?
Another great article. Thank you. Dr. Hickey is perhaps the most clear-sighted author on the MIA team. Well done.
Thanks for the suggestion. I’ll take a look.
Phil, thanks for yet another fantastic, critical, and devastating post!
I have been following the evolution of the “bereavement exception” over time as well as was particularly interested to see how it was treated in DSM-5. During the lead-up to DSM-5, the APA’s website had documents describing rationales for proposed revisions. The mood disorders group clearly wanted to get rid of the bereavement exclusion so grieving people could be diagnosed with “Major Depressive Disorder” and treated with psychiatric drugs. Speaking for the group, psychiatrist Kenneth Kendler wrote, “The DSM-IV position is not logically defensible. Either the grief exclusion criterion needs to be eliminated or extended so that no depression that arises in the setting of adversity would be diagnosable.” As you noted, for a variety of reasons (political, ideological, financial), they could not acknowledge that psychological struggles can be caused by adversity. And so they concluded, once again, that context is irrelevant. If you’re depressed, you should be diagnosed regardless of what has happened to you. If there were any doubt left about the reality that psychiatric diagnoses are context-free, removal of the bereavement exclusion in DSM-5 has dispelled it.
You noted that all the DSM-IV mood disorders work group members had financial ties to drug companies. For DSM-5, 8 of 11 had financial ties, including 6 whose conflicts were ongoing during the time the committee met. Importantly, some of them had conducted industry-funded research on antidepressants for bereavement.
In the UK, it has become popular practice to “screen” for clinical depression using the PHQ9, which is a DSM symptom tick box questionnaire. Like the DSM, it counts “symptoms” and ignores their context. Doctors are encouraged to diagnose and treat people who score above the clinical cutoff. As this article describes, antidepressant prescriptions have doubled in the past decade: http://www.dailymail.co.uk/health/article-3674994/England-s-depression-crisis-Antidepressant-prescriptions-double-decade-costing-NHS-780-000-DAY.html.
Lastly, I’m pleased to see you critique the words of Dr. Pies, which are always seemingly intended to warmly justify whatever it is psychiatrists do. His message here seems to be this: “Patients are too stupid to understand why they are depressed. Psychiatrists know best.” From this condescending position, cloaked in the veneer of science, Pies and his ilk feel free to deem their “patients” mentally ill by counting “symptom” checkboxes and ignoring their psychosocial context.
Thanks for coming in, and for the link. At the present time, psychiatrists have become so emboldened that they almost don’t care how farcical and deceptive their position is. They seem confident that the people will accept any nonsense that they put out. But times are changing.
I hope thing are good in Australia.
Thank you for this articulate description of the harmful hoax of “mental disorders.”
And thank you for your kind and encouraging words.
Dr. Hickey, an absolute masterclass constructed with surgical precision.
A fastidious analysis which documents the commitment of psychiatry to the deception of patients, public and primary care physicians via the marketing, over-diagnosis, and the over -“treatment” of “depression” with some of the most toxic drugs ever licensed .
TRM 123. Retired Consultant Physician.
Thanks for your encouragement.
We need to look outside Psychiatry for answers and solutions: The Wisdom in Dark Emotions
BY MIRIAM GREENSPAN| OCTOBER 6, 2017
Oddly, after 25 years the emotional issues that led me to seek help from psychiatry have resolved themselves. I no longer am afraid to leave my room or talk to people.
Now I just have to cope with hiding my “diagnosis” and essentially my entire past, my iatrogenic illness like CFIDS, and try to figure a way to support myself off SSI. Not sure I can right now, since I tire too easily.
Thanks for coming back. There are few problems in life that psychiatry can’t make a great deal worse.
Thanks for the link.
THIS IS URGENT, because there is a major error in Dr. Hickey’s article here, although he has always before been absolutely accurate and compelling about everything. This is urgent, because the huge numbers of people who were diagnosed with Major Depressive Episode from DSM-IV even during the very earliest stages — even in the first few days of bereavement — will know that it is not true that there was the “bereavement exclusion” that DSM-IV king Allen Frances CLAIMED was in DSM-IV was actually in there. In other words, there was no effective bereavement exclusion. There is something about not diagnosing Major Depression if the person has been bereaved in the past two months. HOWEVER, if you look in the DSM-IV on about the fourth page into the description of Major Depressive Episode, you will see that it says not to diagnose this if the person was bereaved UNLESS the person had ONE of these things — “unless they are associated with marked functional impairment or include morbid preoccupation with worthlessness, suicidal
ideation, psychotic symptoms, or psychomotor retardation” (p.352 of DSM-IVTR). ALL OF THESE ARE absolutely typical of bereavement — NORMAL (I have problems with the words “normal” and “abnormal,” but you know what I mean) bereavement. In other words, Frances’ DSM-IV included the clear specification that normal bereavement even on the day of the loved one’s death SHOULD BE classified as Major Depression (it was Major Depressive Episode). And Joanne Cacciatore and Jeff Lacasse wrote a paper in which they neglected to mention all of the above but importantly documented how speedily bereaved people were put on psychotropic drugs, so clearly by implication, those were people who were not classified as having deeply human, even typical reactions to bereavement but were mentally ill and thus needing drugs. I’ve written about this in these two places and, I think, in something I wrote for MadInAmerica, too:
–Caplan, Paula J. (2014). When you try to speak truth to power, what happens if the powerful turn off their hearing aids? In D. Holmes, J.D. Jacob, & A. Perron (Eds.), Power and the psychiatric apparatus: Repression, transformation, and assistance. Surrey: Ashgate, pp. 165-181.
–Caplan, Paula J. (2013). Psychiatric diagnosis as a last bastion of unregulated, rampant harm to the populace. In M. Dellwing & M. Harbusch (Eds.), Krankheitskonstruktionen und Krankheitstreiberei: Die Renaissance der soziologischen Psychiatriekritik. Wiesbaden: Springer, pp. 351-388.
Thanks for coming in and raising this important issue. I agree with you entirely that DSM-IV effectively eliminated the bereavement exclusion.
I think the confusion has arisen because I didn’t emphasize the point that in DSM-IV, a “diagnosis” of major depression could be given to a bereaved individual without any delay. I didn’t make this point because this provision was already included in DSM-III and DSM-III-R. In those texts, a “diagnosis” of major depression could be given if the depression was “unduly severe or prolonged”. The term prolonged was not defined, but was generally considered at that time to be two years or more.
But – as you point out – the or is critical. A “diagnosis” of major depression could be given to a bereaved person, without any delay, provided only that a case could be made that the grief was “unduly severe”, which is impossibly vague.
The major change in DSM-IV was that the duration was specifically set at two months, but the critical or was still there, allowing the diagnosis to be made on the basis of “undue severity” alone, exactly as had been the case under DSM-III and DSM-III-R.
Concerning DSM-III-R, I wrote:
“So, a bereaved person who met five or more of the nine checklist items for major depression could be given that ‘diagnosis’ if at least one of the easements was also present. At that time, prolonged duration was generally interpreted as more than two years. It should also be noted that there is considerable overlap between the easements and the checklist items, so in many cases, no additional ‘symptoms’ were needed.”
My purpose in that section of the post was to show the development of the bereavement exclusion across the various DSM editions, and I neglected to articulate specifically that the zero delay provision, clearly present in DSM-III and III-R, carried over to DSM-IV.
I regret the confusion, and appreciate the feedback. I have added a clarificatory phrase in the post to the paragraph that begins “Note that the easements have been…” on my website (Behaviorism and Mental Health), and I have asked MIA to make the same addition on their site.
Dr. Hickey, I appreciate your clarification about this matter. But I think it is important to point out that, quite apart from anything related to “unduly severe,” I hope people will read the following criterion from Major Depressive Episode in DSM-IV, noting as you say, the word “or,” so that any ONE item in the list of “marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation” causes the person to meet section “E.” And given that it has been shown (e.g., by Meadow Linder in https://www.amazon.com/Bias-Psychiatric-Diagnosis-Paula-Caplan/dp/0765700018/ref=sr_1_1?ie=UTF8&qid=1508806000&sr=8-1&keywords=Bias+in+psychiatric+diagnosis) that even very caring therapists often assign a psychiatric label even if the person does not meet ALL of the criteria, and given that (as Cacciatore and Lacasse have shown) professionals often immediately prescribe psychiatric drugs for the bereaved and of course have to find and assign a psychiatric label to justify the prescribing, it is clear that, in effect, there was no effective bereavement exclusion in DSM-IV.
E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.