COMMENTARY

Depression or Bereavement? Defining the Distinction

Michael B. First, MD; Ronald W. Pies, MD; Sidney Zisook, MD

Disclosures

April 08, 2011

In This Article

Editor's Note: In revising the Diagnostic and Statistical Manual of Mental Disorders (DSM), the DSM-5 Mood Work Group is proposing the removal of a criterion cautioning clinicians not to make a diagnosis of depression if symptoms are better accounted for by bereavement. Psychiatrists Dr. Ronald Pies and Sidney Zisook support removing this "bereavement exclusion," whereas Dr. Michael First feels it should be left as is, as stated in his recent Current Opinion in Psychiatry article.[1] Medscape recently invited Drs. Pies, Zisook, and First to debate this issue via email and what follows is their virtual discussion.

The Bereavement Exclusion: Background

Michael B. First, MD: From my perspective, changes to the DSM should be made for the purpose of fixing identified problems with the goal of improving the clinical care of our patients. Given that any change to the DSM is inherently disruptive to both clinicians (who must learn the new changes and incorporate them into their practice) and to the research community (since the changes require retooling of diagnostic instruments and create difficulties with regard to comparing studies that used the "old" criteria with studies using the "new" criteria), changes should not be made lightly and should only be done if there are clear empirically established benefits.

Since its first appearance in DSM-III in 1980, the syndromal criteria for a major depressive episode (MDE) included a criterion admonishing the clinician to not mistakenly make a diagnosis of an MDE if the symptoms are better accounted for by bereavement. The reason for including such a criterion was simple: Many of the defining symptoms of an MDE, such as sadness, loss of interest in activities, difficulty sleeping and concentrating, and decreased appetite, can occur as part of a normal grief reaction, especially if they are on the milder side and are relatively short-lived. Given that the duration requirement for an MDE had been set at only 2 weeks (in order to capture cases early in their course), it was easy to envision how cases of normal grief might inappropriately be captured in the "net" of the MDE criteria set. However, in explicit recognition of the fact that the loss of a loved one can trigger a bona fide MDE in susceptible individuals, from DSM-III-R onward a clarifying addendum was added to the bereavement criteria describing types of symptoms that would be more indicative of a grief reaction that has morphed into an MDE, and thus would warrant appropriate diagnosis and treatment (eg, "morbid preoccupation with worthlessness, suicidal ideation, marked functional impairment, or psychomotor retardation or prolonged duration suggest bereavement complication by Major Depression." [DSM-III-R; page 223]).

In the 30+ years of its being included as part of the criteria set for MDE in the DSM-III and through 2 subsequent revisions (DSM-III-R and DSM-IV), no one has ever raised the question that this criterion, which essentially functions as a helpful reminder cautioning clinicians not to inappropriately make a diagnosis of clinical depression in someone who is experiencing uncomplicated bereavement, is somehow preventing clinicians from making an appropriate diagnosis of MDE in cases in which the clinical picture is no longer consistent with normal grief. Furthermore, as far as I am aware there is no empirical evidence that this criterion is the source of any diagnostic or management problem and therefore represents something "broken" with the DSM that needs to be fixed. While a number of studies have been done that suggest that major depression is often underrecognized and undertreated in a number of settings, there is no evidence that the problem is in any way of consequence of this longstanding criterion.

The impetus to eliminate this criterion appears to stem from the DSM-V Mood Disorder Work Group's attempt to correct a long-recognized logical inconsistency in the criteria set for major depressive disorder (MDD). As noted previously, the motivation for including this criterion in the first place is to reduce the likelihood that clinicians will inappropriately diagnose a normal grief reaction as clinical depression. However, although the loss of a loved one is among the most significant losses that we experience as human beings, there are many other severe losses (such as the breakup of a serious romantic relationship) that can lead to a normal grief-like reaction. Why should the DSM criteria set single out the loss of a loved one and not also consider other similarly severe losses? There are, of course, 2 ways to "fix" this logical problem (assuming it is important enough to fix in the first place): to extend the "not better accounted for by bereavement" criterion to include other severe losses (a position advocated by Hurwitz and Wakefield in their book Loss of Sadness[2]), or to eliminate it altogether as proposed by the DSM-V Mood Disorder Work Group.

The problem with extending this exclusion to include other stressors is how to develop a reliable and valid method to assist the clinician with his or her determination as to whether the depressive symptoms occurring after a severe loss are a "normal" nonpathological reaction to the stressor or whether they are best considered indicative of an MDE. Wakefield has suggested that a "proportionality" determination be used as a guide, ie, the clinician would determine whether the severity of the depressive reaction is proportional to the severity of the stressor; if it is, that the reaction would be considered nonpathological. While conceptually appealing, the reliability and validity of such a determination in clinical settings is an open empirical question, suggesting that adopting such an approach without supporting empirical data would be premature.

On the other hand, fixing the problem by eliminating the bereavement "exclusion" altogether (as is being proposed for DSM-V) carries with it a number of potential significant costs. First of all, there is significant potential for harm to our grieving patients. Inappropriately diagnosing a normal grief reaction as an MDE takes a normal human emotion and reframes it as evidence of sickness, which may result in unnecessary treatment, stigmatization by family, friends, and self, and other negative discriminatory effects, such as being unable to obtain disability insurance or life insurance in the future because of having a diagnosis of MDD in one's medical record. A skeptic might wonder under what conceivable circumstances might someone who considers himself to be experiencing normal grief be mislabeled as having an MDE. Especially in our current cultural climate in which people commonly seek out medication from their primary care clinician for symptomatic relief of anxiety and insomnia, it is not hard to imagine how that clinician might feel pressured to write down a diagnosis of MDD on the chart (with all of the future potential for negative consequences) in order to justify the writing of a prescription for a psychotropic medication.

From the clinician perspective, the cost of eliminating the bereavement exclusion is to encourage the reification of the major depressive syndrome which, contrary to appearances, does not define a real disease but merely describes the fact that a particular set of symptoms has clustered together during the same 2-week period. Its removal is basically sending the message that clinical judgment is not required when making a psychiatric diagnosis; simply checking off whether the syndromal criteria for an MDE is met is sufficient to determine that the individual is suffering from clinical depression. Finally, by eliminating an exclusion criterion explicitly designed to avoid obvious false positives (eg, normal grief), the DSM-V Mood Disorder Work Group's proposal provides fodder to a skeptical public who suspects that a main goal of the DSM-V is to increase business for mental health professionals.

Although maintaining this worthwhile criterion in the DSM-V criteria for MDE would result in the continued perpetuation of the logical inconsistency of handling the loss of a loved one differently than other stressors, any attempt to "fix" this conceptual problem by either eliminating the criterion or expanding it to include other stressors will end up making the situation much worse. Of course, given that the risk of making a false-positive diagnosis in someone experiencing normal grief is largely a consequence of the DSM-IV having a relatively low duration and severity threshold for a diagnosis of MDE, ramping up the duration and severity threshold could largely solve the problem, obviating the need for this criterion in the first place. However, for a variety of reasons (including loss of continuity with the prior 30 years of clinical research on depression and the risk of exacerbating the underrecognition and undertreatment of depression), the cost of this solution might be even worse. Perhaps at some point in the distant future, when the diagnosis of clinical depression can be made based on objective laboratory testing, the dilemma of how to validly differentiate clinical depression and normal grief will be solved. However, until such a test is available and in the absence of empirical evidence that this criterion is creating any kind of problem for clinicians or our patients, I believe that this is one of the situations in which it is better to just leave well enough alone.

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