Editorials

Grief and Major Depression—Controversy Over Changes in DSM-5 Diagnostic Criteria

 


FREE PREVIEW. AAFP members and paid subscribers: Log in to get free access. All others: Purchase online access.


FREE PREVIEW. Purchase online access to read the full version of this article.

Am Fam Physician. 2014 Nov 15;90(10):690-694.

In May 2013, the American Psychiatric Association released the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).1 One of the more controversial revisions in the DSM-5 is the elimination of the bereavement exclusion criterion for major depressive disorder (MDD), suggesting to some that grief is not a normal process. Within the DSM-IV, text revision,2  persons who experienced the death of a loved one and who had a depressed mood would not be diagnosed with MDD unless symptoms persisted beyond two months or were characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. In the DSM-5, a note replaces what has traditionally been referred to as the bereavement exclusion criterion, or criterion E, for MDD in the DSM-IV, text revision. The note suggests that responses to any significant loss may include symptoms resembling a depressive episode, and although they may be understandable or appropriate to the loss, the presence of a major depressive episode should be considered carefully. In a footnote, the DSM-5 provides additional guidance on how to differentiate grief from MDD. To allow for diagnostic flexibility, the DSM-5 provides another option for noting normal reactions to the death of a loved one by including uncomplicated bereavement in the chapter titled “Other Conditions That May Be a Focus of Clinical Attention” (V62.82). Table 1 provides information on differentiating normal bereavement from a major depressive episode.1,35

View/Print Table

Table 1.

Differentiating Normal Bereavement from Major Depressive Episode

CharacteristicBereavementMajor depressive episode

Pattern

Waves or pangs of grief associated with thoughts or reminders of the deceased that are likely to spread further apart over time

Negative emotions experienced continually over time

Predominant affect

Emptiness and loss accompanied by occasional pleasant emotions

Pervasive depressed mood and the inability to anticipate happiness or pleasure

Self-esteem

Typically preserved, but if self-derogatory thoughts are present they usually involve perceived failings in relationship to the deceased (e.g., not visiting the deceased more often, failing to communicate their love enough to the deceased)

Critical toward self, feelings of worthlessness, and self-loathing

Sociability

Maintains connections with family and friends who have ability to console

Withdraws from others physically and emotionally and has difficulty being consoled

Thoughts

Preoccupation with thoughts and memories of the deceased; tends to be hopeful

Self-critical or pessimistic thoughts; tends to be hopeless

Thoughts of death or suicide

Thoughts of death and dying focused on the deceased and perhaps reuniting with the deceased

Explicit suicidal thoughts related to feelings of worthlessness, a belief that one is undeserving of life, or a sense that one is no longer able to cope with the pain of depression

Triggers

Depressed mood triggered by thoughts or reminders of the deceased

Depressed mood not tied to specific thoughts or preoccupations


Information from references 1, and 3 through 5.

Table 1.

Differentiating Normal Bereavement from Major Depressive Episode

CharacteristicBereavementMajor depressive episode

Pattern

Waves or pangs of grief associated with thoughts or reminders of the deceased that are likely to spread further apart over time

Negative emotions experienced continually over time

Predominant affect

Emptiness and loss accompanied by occasional pleasant emotions

Pervasive depressed mood and the inability to anticipate happiness or pleasure

Self-esteem

Typically preserved, but if self-derogatory thoughts are present they usually involve perceived failings in relationship to the deceased (e.g., not visiting the deceased more often, failing to communicate their love enough to the deceased)

Critical toward self, feelings of worthlessness, and self-loathing

Sociability

Maintains connections with family and friends who have ability to console

Withdraws from others physically and emotionally and has difficulty being consoled

Thoughts

Preoccupation with thoughts and memories of the deceased; tends to be hopeful

Self-critical or pessimistic thoughts; tends to be hopeless

Thoughts of death or suicide

Thoughts of death and dying focused on the deceased and perhaps reuniting with the deceased

Explicit suicidal thoughts related to feelings of worthlessness, a belief that one is undeserving of life, or a sense that one is no longer able to cope with the pain of depression

Triggers

Depressed mood triggered by thoughts or reminders of the deceased

Depressed mood not tied to specific thoughts or preoccupations


Information from references 1, and 3 through 5.

Several reasons have been proffered for eliminating the bereavement exclusion criterion. These include: (1) removing the implication that bereavement typically lasts only two months; (2) recognizing bereavement as a severe psychological stressor that can precipitate MDD in vulnerable persons; (3) understanding that bereavement-related major depression is genetically influenced and is associated with similar personality characteristics, patterns of comorbidity, course, and risks of chronicity and recurrence as non–bereavement-related MDD; and (4) seeing that bereavement-related depression responds similarly to psychosocial and pharmacologic treatments as non–bereavement-related depression.6,7 Those favoring the elimination of the bereavement exclusion criterion also note that MDD can occur in someone who is grieving, just as it may occur in persons experiencing other types of stressors or losses (e.g., job loss); yet, the presence of those stressors does not preclude a diagnosis of depression.7 Proponents of eliminating the bereavement exclusion criterion accept the risk of stigmatizing grieving patients with a mental health diagnosis because this risk is outweighed by the potential for proper clinical attention and treatment of depression5 and the prevention of suicide.8,9

Many reasons exist to maintain the bereavement exclusion criterion. First, despite claims that MDD and bereavement-related depression are similar,3,10,11 evidence suggests otherwise.12,13 One study found that single, brief, bereavement-related depressive episodes have distinct demographic and symptom profiles compared with other types of depression, and that these bereavement-related depressive symptoms were not associated with increased risk of future depression.12 A literature review found no support for arguments contesting the bereavement exclusion criterion.13 This review also found no increased risk of suicide among persons with excluded bereavement-related depression. Eliminating the bereavement exclusion criterion will also result in an increasing number of persons with normal grief to be inappropriately diagnosed with MDD after only two weeks of depressive symptoms. Not only is the grieving patient now stigmatized with a mental health disorder, but clinicians may unnecessarily prescribe antidepressant medications, exposing patients to the associated adverse effects.4 With nearly 2.5 million deaths each year in the United States,14 the harm associated with the inappropriate diagnosis and treatment of grieving patients is apparent and disturbing. For grieving patients with more serious depression, the DSM-IV, text revision, allows a diagnosis of MDD if certain conditions exist.

Rather than arguing for the presence or removal of the bereavement exclusion criterion for depression, we suggest the following steps. First, future studies should continue to focus on differentiating bereavement-related depression from non–bereavement-related depression to enhance a clinician's ability to properly assess and manage each. Second, efforts at proper education and training of students, residents, and clinicians on recognizing and responding to depression in grieving patients should be enhanced, with most of the education geared toward primary care physicians who care for the majority of grieving patients. Finally, clinicians should take the time necessary to monitor their patients, and to provide counseling and possibly referral, knowing that some grieving patients may develop more severe symptoms of depression and, thus, may need more than time alone to heal.

Address correspondence to Michael G. Kavan, PhD, at michaelkavan@creighton.edu. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013....

2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision. Washington, DC: American Psychiatric Association; 2000.

3. Zisook S, Corruble E, Duan N, et al. The bereavement exclusion and DSM-5 [published correction appears in Depress Anxiety. 2012;29(7):665]. Depress Anxiety. 2012;29(5):425–443.

4. Friedman RA. Grief, depression, and the DSM-5. N Engl J Med. 2012;366(20):1855–1857.

5. Pies R. Bereavement does not immunize the grieving person against major depression. GeriPal: a geriatrics palliative care blog. December 4, 2012. http://www.geripal.org/2012/12/bereavement-does-not-immunize-grieving_4.html. Accessed April 21, 2014.

6. American Psychiatric Association. Highlights of changes from DSM-IV-TR to DSM-5. http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf. Accessed April 21, 2014.

7. Zisook S Getting past the grief over grief. Sci Am. February 25, 2013. http://blogs.scientificamerican.com/guest-blog/2013/02/25/getting-past-the-grief-over-grief/. Accessed April 21, 2014.

8. Ajdacic-Gross V, Ring M, Gadola E, et al. Suicide after bereavement: an overlooked problem. Psychol Med. 2008;38(5):673–676.

9. Stroebe M, Stroebe W, Abakoumkin G. The broken heart: suicidal ideation in bereavement. Am J Psychiatry. 2005;162(11):2178–2180.

10. Lamb K, Pies R, Zisook S. The bereavement exclusion for the diagnosis of major depression: to be, or not to be. Psychiatry (Edgmont). 2010;7(7):19–25.

11. Zisook S, Shear K, Kendler KS. Validity of the bereavement exclusion criterion for the diagnosis of major depressive episode. World Psychiatry. 2007;6(2):102–107.

12. Mojtabai R. Bereavement-related depressive episodes: characteristics, 3-year course, and implications for the DSM-5. Arch Gen Psychiatry. 2011;68(9):920–928.

13. Wakefield JC, First MB. Validity of the bereavement exclusion to major depression: does the empirical evidence support the proposal to eliminate the exclusion in DSM-5? World Psychiatry. 2012;11(1):3–10.

14. Centers for Disease Control and Prevention. FastStats: death and mortality. http://www.cdc.gov/nchs/fastats/deaths.htm. Accessed April 21, 2014.



 

Copyright © 2014 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


More in AFP


Editor's Collections


Related Content


More in Pubmed

MOST RECENT ISSUE


Sep 15, 2016

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article