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

Can Grief Morph Into Depression?

4. "...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...eg, morbid preoccupation with worthlessness, suicidal ideation...[etc]..."

  • Perhaps the notion of a grief reaction that has "morphed into an MDE" was part of the DSM-III-R framers' thinking; however, to our knowledge, this putative "pathway" is not mentioned in either the DSM criteria or in the accompanying text. We believe that this notion of grief somehow "turning into" depression after some period is the fundamental misunderstanding that many researchers, clinicians, and bereaved individual alike bring to the table. Grief and major depression are fundamentally different conditions. To be sure: both can and often do occur after the death of a loved one, and both may be exquisitely painful. Both can make a person sad and withdrawn. Both grief and major depression may show marked variability, with some cases relatively mild and short lived, and others, severe and persistent. However, unlike major depression, ordinary grief is adaptive and characteristically contains a broad mixture of negative and positive emotions. Thus, at times, the bereaved may experience longing, loneliness, yearning, preoccupation with the deceased, and waves of distress triggered by memories or reminders of the deceased. At other times -- or admixed with such negative emotions -- the grieving person may experience feelings of relief, pride in past accomplishments, and pleasant memories of the deceased. The key emotion in ordinary bereavement is a feeling of loss. (Interestingly, the etymology of the word "bereavement" precisely reflects this, and is derived from O.E. bereafian: "to deprive of, take away, seize, rob").

    In contrast, the key emotion in major depression is sadness tinged with hopelessness and despair. Moreover, in major depression, anhedonia and diminished self worth are usually pervasive and intractable. Pleasant memories, feelings of relief or pride, and expressions of humor are not characteristically part of the emotional repertoire in major depression.

    Most bereaved individuals grieve and feel "depressed" (small d); some develop MDE (large D). Some grieve intensely and for extended periods (months or years) without ever meeting criteria for an MDE; in contrast, many individuals with depression -- whether mild or severe -- have never been bereaved. In short, ordinary grief and major depression are simply different constructs with differing phenomenology (the "inner experience" of the sufferer). Grief, no matter how severe, does not "morph into depression," though some bereaved individuals may develop an MDE -- sometimes immediately after the death, sometimes weeks or months later. Their grief, however, has not metamorphosed or "morphed" into something else; rather, their grief persists and may become even more severe and resistant to the healing powers of time. In some cases, the grief may evolve into what some investigators call "complicated grief" and others call a "prolonged grief reaction."[11] Although "complicated grief" or "prolonged grief" often co-occurs with MDE or post-traumatic stress disorder, the data are quite compelling that even these severe, nonadaptive variants of grief are distinguishable from major depression -- and, like ordinary grief, represent distinct constructs.[10]

    Finally, the current DSM-IV "conditional" criteria symptoms to which Dr. First appeals (excessive guilt, psychomotor change, etc) may be present from the very first day of illness onset -- not as indicators that grief has "morphed" into major depression. More important, evidence from a large (N = 399) field study using clinical psychologist interviewers and structured interviews (as distinct from community surveys administered by nonclinicians) found that the DSM-IV "conditional criteria" do not reliably help identify a more severely depressed group of patients.[12] Ironically, research by Corruble and colleagues has found that 2 of these conditional criteria (suicidal ideation and feelings of worthlessness) may actually be more common in "bereavement-excluded" patients(ie, those who met symptom criteria for MDD, but were not diagnosed with MDD because of recent bereavement) than in those diagnosed with MDD after bereavement.[13]

    In short, we find no compelling clinical evidence that grief "morphs" into major depression, or that the DSM-IV conditional criteria represent a "clarifying" or clinically useful construct.

5. "In the 30+ years of its being included...no one has ever raised the question that this [bereavement exclusion] criterion...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...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."

  • On the contrary, Corruble and colleagues[13]do have worrisome data pointing to clinical problems when the current DSM-IV bereavement "rules" are applied to patients presenting with depression. In a large, case-control, cross-sectional study of a national database in France, Corruble and colleagues found that "bereavement-excluded patients" (ie, individuals who met symptom criteria for MDD, but were not diagnosed with MDD because of recent bereavement) were more severely depressed than MDE controls without bereavement and similar to MDE controls with bereavement.[13] The authors concluded that use of the DSM-IV bereavement exclusion could "...result in patients failing to be correctly diagnosed...and not getting appropriate treatment."

6. "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."

  • We generally agree. Underrecognition of MDD probably stems from inadequate assessment, rushed diagnosis, and the failure to apply DSM criteria,[14] mainly in primary care settings. On the other hand, to our knowledge, there are no methodologically rigorous clinical studies showing that clinicians tend to misdiagnose ordinary grief as MDE. Indeed, as Dr. First correctly notes, nearly all the available studies point to underrecognition of MDE.[9,10] We are not aware of a single study that demonstrated, in a clinical population, that patients with normal grief were mistakenly "overdiagnosed" as having MDD.

7. "... 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...or to eliminate it altogether as proposed by the DSM-V Mood Disorder Work Group.... 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...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."

  • We fully agree with this last point. One of us (RP) has reviewed the reasons why sorting out depression "with cause" (the so-called "depressive reaction") from depression "without cause" -- as Horwitz and Wakefield would have us do -- is extremely difficult in practice.[15] Kessing reached a similar conclusion.[16] Premature closure on the supposed "cause" of a depressive episode is often simplistic and misleading (eg, a patient who seems to have become depressed after job loss may actually have lost his job because his incipient depression interfered with performance). Moreover, we believe the construct of "proportionality" is highly subjective and likely to differ widely from culture to culture.[15]

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