Depression or Bereavement? Defining the Distinction

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


April 08, 2011

In This Article

The Disagreement

Ronald W. Pies, MD, and Sidney Zisook, MD: We enjoyed reading Michael First's argument for retaining the bereavement exclusion in DSM-V.[1] As always, he makes several excellent points; in fact, we agree with many of his assertions. We also appreciate the considerable expertise Dr. First brings to the complex issue of psychiatric diagnosis and the DSM. However, there remain key disagreements. Here, we address each of Dr. First's points (in italics), one by one:

1. "...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."

  • We fully agree!

2. "...changes should not be made lightly and should only be done if there are clear, empirically established benefits."

  • We agree, with the proviso that when empirical evidence casts substantial doubt on a previous diagnostic category, it is reasonable to consider eliminating it. Recently, this principle has been affirmed in dramatic fashion with the proposed elimination of several personality disorders by the Personality Disorders Work Group. We believe the same is true of the bereavement exclusion, given that several reviews and recent population-based empirical studies[3,4,5,6] have found that bereavement-related depressive episodes and nonbereavement-related depressive episodes are more similar than different. In our view, this invalidates the distinction and provides ample data to justify eliminating the bereavement exclusion from DSM-V.

3. "Since its first appearance in DSM-III in 1980, the syndromal criteria for an 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...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."

  • We find the phrase "better accounted for" deeply problematic. What empirical test determines that a bereaved patient's depressive symptoms are "better accounted for" by bereavement than major depression, when the patient meets all symptom and duration criteria for MDE? Neither our clinical experience nor any controlled data we know of support the claim that any current MDE features are common elements of "normal grief" when they occur most days for 2 weeks and significantly interfere with social/vocational function. It is important to note that the Paula Clayton's classic studies of bereavement in the 1970s[7] used the Feighner criteria for major depression. These criteria are similar to present-day DSM criteria but do not include the important component of significant social/vocational impairment.

  • With respect to the current 2-week duration criterion for MDD, we agree that this is usually too brief to reach a confident diagnostic conclusion: ie, to determine the "trajectory" of the patient's depressive symptoms. We have suggested a more fine-grained approach, in which, for most first-episode, nonmelancholic, nonpsychotic presentations of depression, a 1-month minimal duration may be more useful as a basis for defining pathology and need for treatment. Duration and severity are important dimensions of depression that require further characterization.[6,8]

  • Nonetheless, we are not aware of any empirical studies demonstrating that actual cases of normal grief were inappropriately "captured in the net of the MDE criteria set." In contrast, there are numerous studies pointing to underrecognition of MDD in primary care settings.[9,10]


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