SAE will be providing a series of Issue Briefs (IBs) on the clinical changes and updates noted in the Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition (DSM-V). Clinical criteria changes, cluster changes, outcome measures, as well as measures of fidelity to the treatment model will be featured in these special clinically focused IBs. We welcome you to think critically with our team of expert clinicians, researchers and evaluators as we go in depth on selected high-risk, high-prevalence and complex care populations.
The restructuring of the DSM-V goes beyond the technical changes of moving from a multi-axial diagnosis to a non-axial diagnosis. Cluster and criteria changes abound with resonating effects on the clinical process for diagnosis and treatment, as well as the administrative and research processes that guide the development of outcome measures and protocols for gaps-in-care with high risk populations. A critical analysis of these changes within the model of integrated care is necessary, given the strong data on co-occurring disorders and the categorization of "chronic complex care".
For example, a significant criteria change in the diagnosis of Major Depressive Disorder (MDD) is the previous "Bereavement Exclusion" noted in the DSM-IV. Whereas clinicians were advised to not diagnose MDD in individuals who experienced a recent death of a loved one within the first two months, the current criteria change in the DSM-V does not follow the same restriction. A distinction is made to clarify that grief of a lost one does not act as a protective function of MDD. A co-occurrence should not be ruled out and, in fact, bereavement may precipitate MDD in vulnerable populations already struggling with acute stressors, adjustment to natural life changes and/or a pre-existing chronic psychiatric condition.
Clarification of distinguishing features are as follows:
- "In grief, painful feelings come in waves, often intermixed with positive memories of the deceased; in depression, mood and ideation are almost constantly negative."
- "In grief, self-esteem is usually preserved; in MDD, corrosive feelings of worthlessness and self-loathing are common."
- "While many believe that some form of depression is a normal consequence of bereavement, MDD should not be diagnosed in the context of bereavement, since diagnosis would incorrectly label a normal process as a disorder."
Source: American Psychiatric Association
The clinical application of this criteria change involves: educating clinical staff; making the infrastructure changes in the documentation process for screening, assessment and treatment planning and progress notes; integrating necessary clinical content material on acute and prolonged experience of distress, of grief and loss co-occurring with MDD into protocols in practice; and developing clear measures of treatment impact to capture symptom relief, change in function and sustained process of motivation.
With the treatment of an individual with MDD complicated by grief and a chronic health condition, such as diabetes or hypertension, a thinking process for an integrated clinical approach could include the following:
- Journaling on how the relationship loss effects self-care taking practices (eating pattern, sleep pattern, social pattern, medication adherence, etc.) and comparing rates on motivation to change with behavioral indicators for each daily function.
- Coping skills related to grief and loss that helps the expression of positive self-care, such as walking familiar neighborhoods shared with the loved one. This would lower social isolation, decrease physical inactivity, thus promoting weight control, a safety plan for emotional triggers to address maladaptive thoughts and risk behaviors, and an involvement with a social support for the activity would increase emotional connection with a recovery peer community.
- Tracking of MDD symptoms that are exacerbated by thoughts of loved ones and the maladaptive automatic thoughts leading to risky behaviors lowering motivation to change. This would involve ensuring clinical charting processes that identify behavioral indicators of change as well as documenting the process of engaging the patient with self-reports, state of self-care, and understanding of patient education materials.
An integrated care practice for individuals with MDD with a complicated grief and loss must address the physical and emotional process of self-care, motivation for adherence to needed physical as well as emotional treatment goals and care planning that allows the patient to self-monitor, self-report and self-manage the accompanying stress that comes with living with complex chronic conditions.
Why is this important?
Complex care patients not only cost the system in terms of services, but also because they have a lower life expectancy of up to 25 years, due to premature death resulting from inadequate and uncoordinated care. We're not just dealing with some numbers and trends; lives are at stake here, and we need to recognize that.