Depression or Bereavement? Defining the Distinction

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


April 08, 2011

In This Article

Tightening Depression Criteria: A Possible Solution?

14. "...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 [MDE], ramping up the duration and severity threshold could largely solve the problem, obviating the need for this [bereavement exclusion] criterion...However, for a variety of reasons (including loss of continuity with... 30 years of clinical research...and the risk of exacerbating the underrecognition and undertreatment of depression) the cost of this solution might be even worse. Perhaps...when the diagnosis of clinical depression can be made based [via] objective laboratory testing, the dilemma of how to validly differentiate clinical depression and normal grief will be solved."

  • We agree that tightening the severity and duration criteria for MDE[21] is a better way of reducing "false positives" than retaining the bereavement exclusion. Moreover, we believe that with careful attention to phenomenology[7,20], we can make accurate clinical distinctions now, without recourse to biomarkers or lab testing. Though we certainly believe that such biomarkers or endophenotypes are well worth pursuing, we also acknowledge the need for empirical studies to validate our belief.

15. "I believe that this is one of the situations in which it is better to just leave well enough alone."

  • Again, Dr. First puts his finger on a key issue. But are we doing well enough? Our own experiences as well as the best available data overwhelmingly suggest that MDE is all too often not diagnosed, but rather misattributed to, or misdiagnosed as, "stress." We have seen the tragic results of exposing depressed individuals to the resultant undertreatment, or no treatment, of what we know to be a potentially fatal illness. This is 1 area where the underdiagnosis and undertreatment are iatrogenic and can be corrected. Let's do it.


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