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guest editorial
This issue:
Bereavement, Depression, and the DSM-5
Sidney Zisook, MD; and M. Katherine Shear, MD
Guest Editors
N
o diagnostic proposal has
been more hotly debated
than the American Psychiatric Association (APA) Mood Disorder
Task Force’s recommendation to remove the bereavement exclusion from
the diagnosis of major depressive disorder (MDD) for the Diagnostic and
Statistical Manual of Mental Disorders, fifth edition (DSM-5).
The bereavement exclusion in
DSM-IV proscribes the diagnosis
MDD when depressive symptoms
fall within 2 months of the death of
a loved one, and does not include
marked functional impairment, morbid preoccupation with worthlessness,
active suicidal ideation, psychomotor
retardation, or psychotic features.1
Yet in spite of the contentiousness,
there are many important points of
agreement. No one disputes that bereavement is a universal experience,
nor that grief can be inordinately
painful, distressing, and protracted.
And despite accusations to the contrary, we can claim confidently that
DSM-5 does not seek to pathologize
human reaction. There also is agreement that MDD is a serious condition
that should be diagnosed and treated,
as it can be worsened or triggered by
stressful life events, and that bereavement itself is a stressful life event.
Further, there is ample agreement that
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a major depressive episode (MDE)
shares some features of acute grief,
making the differential diagnosis
challenging. Proponents of each side
of this debate feel strongly that they
are on the “right” side of the evidence,
of compassion for suffering, and of
their professional obligation to protect
the public. The intent of this collection
of articles is to shed additional light on
this diagnostic and clinical dispute.
DIAGNOSTIC BOUNDARY
The passionate disagreement is
about how to conceptualize and define
the diagnostic boundary between grief
and MDD. Those in favor of retaining
the exclusion argue that there are fundamental differences between those
depressive syndromes that are targeted by the bereavement exclusion (BE)
and other, nonbereavement-related instances of MDD,2 whereas proponents
in favor of removing the BE argue that
data support the similarity of bereavement-related depression and MDD,
regardless of the context.3 It is worth
noting that no rigorous prospective
study has been done to specifically
answer the question of whether there
are important, clinically significant
differences between MDD after bereavement compared with MDD that
occurs in other contexts. Therefore,
the authors of DSM-5 needed to make
their best judgment about this challenging issue.
Those who want to retain the exclusion claim that its removal will
medicalize normal grief; label and
stigmatize bereaved people; and lead
to harmful, inappropriate, and injudicious use of pharmacologic interventions for normal sadness. They point
to epidemiologic data that individuals
excluded from the diagnosis of MDD
on the basis of the BE are less likely
to experience recurrent episodes than
are other individuals with MDD. They
argue that it is important to exclude
mild and brief depressive syndromes
because these cannot be easily differentiated from normal grief. In addition, they assert that without a specific
bereavement exclusion, many people
suffering bereavement would be burdened further by being misunderstood
and inappropriately labeled and treated as mentally ill.4
We, the authors of this commentary,
are on the other side of this debate: we
believe the BE should be eliminated
on the premise that MDD is a serious,
highly recurrent, potentially fatal disorder regardless of its apparent cause
or precipitant. Furthermore, MDD has
been shown to have negative health effects even in its milder form. The BE
creates a roadblock to diagnosis and
treatment that may improve a person’s
PSYCHIATRIC ANNALS 43:6 | JUNE 2013
guest editorial
quality of-life as well as enhance the
capacity to effectively grieve.
The diagnostic challenges are
similar to the diagnostic dilemmas
posed by medically ill patients whose
depressive symptoms overlap with
physical illness. We now know that
the presence of a syndromal cluster of
depressive symptoms in a medically
ill patient is clinically significant,
regardless of the cause of the symptoms; depression impedes healing and
is associated with impaired functioning and quality of life, and increased
morbidity and mortality.5 Similarly,
most of the available evidence shows
that MDD occurring soon after bereavement is clinically meaningful,
not unlike MDD occurring in other
contexts.3 In both cases, following
general medical illness or after bereavement, diagnosing MDD can be
challenging but may be a vital step
towards healing and well-being.
SMALL ‘D’ VS. BIG ‘D’ DEPRESSION
A key conceptual issue that creates
considerable confusion and fuels the
debate is whether to diagnose depression instead of, or in addition to, grief.
Proponents of retaining the BE are
focused on the differential diagnosis
of grief and MDD, whereas those of
us who favor eliminating the exclusion believe that this presupposes a
false dichotomy; grief and MDD are
not mutually exclusive. The problem
hinges on the common symptom of
sadness. Depression has two separate
meanings: One is a synonym for sadness and the other is the name of a
mood disorder. Small ‘d’ depression
is always associated with grief, and
is, in fact, a common experience for
most people. To say a bereaved person
is depressed (small ‘d’) is to describe
PSYCHIATRIC ANNALS 43:6 | JUNE 2013
a key feature of grief. Big ‘D’ depression refers to the psychiatric condition, MDD, which is a serious medical
condition that is not a feature of ordinary grief. When MDD is diagnosed
in response to the loss of a loved one,
it is not diagnosed instead of grief, but
rather in addition to grief.
Many, if not most, bereaved individuals never meet full criteria for
MDD. Among those who do, the depression runs the gamut of severity,
with some being quite mild and brief,
others being severe and persistent,
and most being somewhere in the
middle. However, even relatively mild
depressive episodes are clinically significant.6 Moreover, when someone
is struggling to come to terms with a
difficult loss, even a mild MDD can
impede healing.
DURATION OF GRIEF
A corollary of the proposition that
grief and MDD cannot co-occur is
that you cannot diagnose MDD unless grief is no longer present. The
BE implies that grief should be resolved by 2 months. However, as
grief researchers, we are cognizant
that grief is never over.7 Loss is forever; so is grief. What changes over
time is the intensity and dominance of
grief symptoms. We favor eliminating
the BE, not because we believe grief
should be completed in less than 2
weeks or even in 2 months, but rather
because we believe that co-occurring
MDD can further prolong and worsen
an already difficult grieving process.8
DIAGNOSIS OF MDD WHEN GRIEF
IS PRESENT
Each of the articles in this issue of
Psychiatric Annals addresses the question of diagnosing MDD in the face of
bereavement and grief. The articles
emanate from studies conducted globally and were authored or co-authored
by some of the most senior pioneers of
the scientific study of bereavement and
MDD. Paula L. Hensley, MD, and
Paula J. Clayton, MD (see page 256)
describe Dr. Clayton’s original series
of elegant, ground-breaking studies
that were among the first methodologically rigorous, longitudinal studies of
depression in bereaved persons, leading the framers of DSM-III to adopt
the bereavement exclusion.9
Alana Iglewicz, MD; Kathryn Seay, BS; Stefani Vigeant, BS;
Sandeep Kaur Jouhal, MD; and
Sidney Zisook, MD (see page 261)
critically review arguments for and
against the elimination of the BE10
and conclude that the advantages of
retaining the BE are outweighed by
the advantages of removing it, both in
terms of alliance with the best available data and with the interest of optimal patient care.
Elie G. Karam, MD; Caroline
C. Tabet, DEA; and Lynn A. Itani,
MPH (see page 267) summarize data
from a large, population-based, prospective field study that compared
symptom profiles, dysfunction, duration of illness, and risk of recurrence
among nonbereaved and bereaved
individuals who met DSM-IV criteria
for MDE.11 They show that bereavement-related and nonbereavment-related depressive episodes are similar
in almost all respects, including impairment and recurrence.
Emmanuelle Corruble, MD, PhD
(see page 272) reports on two naturalistic studies from large, French national
case-control samples of self-referred
individuals seeking treatment for depressive symptoms.12 Findings from
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guest editorial
these studies suggest that the bereavement exclusion is confusing and often
is misused.
Diana Paksarian, MPH, and Ramin Mojtabai, MD, PhD, MPH (see
page 276) conducted secondary analyses of three studies from the National
Epidemiologic Survey on Alcohol and
Related Conditions (NESARC) and
Epidemiologic Catchment Area (ECA)
databases that demonstrated low recurrence rates for ‘bereavement-excluded’
depressions,13 concluding that the BE is
warranted and should have been maintained in DSM-5.
The issue concludes with an essay
by Ronald Pies, MD (see page 286)
that compares how grief and MDD
are experienced. Pies argues that grief
and MDD are fundamentally different
constructs, that they can coexist, and
further, that grief does not transform to
depression with the passage of time.14
Pies stresses the importance of accurate diagnosis as a prelude to appropriately targeted care.
Together, this collection of articles
provides the reader with a comprehensive look for and against the BE.
More important, these articles offer
clinicians critical information to understand, diagnose, and treat bereaved
patients who are also burdened with
persistent, pervasive, and pathological
depressive symptoms.
doi: 10.3928/00485713-20130605-03
REFERENCES
1.American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.
2.First MB, Pies RW, Zisook S: Depression
or bereavement? Defining the distinction.
Available at: www.medscape.com/viewarticle/740333. Accessed on May 21, 2013.
3. Zisook S, Corruble E, Duan N, et al. The bereavement exclusion and DSM-5. Depress
Anxiety. 2012;29(5):425-443.
4.Wakefield JC, Schmitz MF: Normal vs.
disordered bereavement-related depression:
are the differences real or tautological? Acta
Psychiatr Scand. 2013;127(2):159-168.
5.Cassem E Depressive disorders in the
medically ill: an overview. Psychosomatics.
1995;36:S2-S10
6.Zisook S, Paulus M, Shuchter SR, Judd
LL. The many faces of depression following spousal bereavement. J Affect Disord.
1997;45:85-95.
7. Shear MK, Simon N, Wall M et al.: Complicated grief and related bereavement issues
for DSM-5. Depress Anxiety. 2011;28:103117.
8.Zisook S, Shuchter SR: Uncomplicated bereavement. J Clin Psychiatry. 1993;54:365372
9. Clayton P, Hensley P. In the beginning: why
the bereavement exclusion was introduced
in DSM-III. Psychiatr Ann. 2013;43(6):256260.
10.Iglewicz A. The bereavement exclusion:
finding the truth between pathologizing and
politicizing. Psychiatr Ann. 2013;43(6):261266.
11. Karam E, Tabet C, Itani L. The bereavement
exclusion criterion in depression: findings
from a field study in Lebanon. Psychiatr
Ann. 2013;43(6):267-271.
12.Corruble E. The discriminant validity of
DSM-IV bereavement exclusion for the
diagnosis of major depression: results of
naturalistic real-world studies in France.
Psychiatr Ann. 2013;43(6):272-275.
13.Paksarian D, Mojtabair R. Distinguishing
bereavement from depression in DSM-5:
evidence from longitudinal epidemiologic
surveys. Psychiatr Ann. 2013;43(6):276282.
14.Pies R. Grief or major depression? Moving from “context” toward phenomenology.
Psychiatr Ann. 2013;43(6):286-290.
about the guest editors
Sidney Zisook, MD, is a Distinguished Professor of Psychiatry
and Residency Training Program
Director at the University of California at San Diego; Research
Scientist at the Veterans Medical
Research Foundation; and Staff
Physician, VA San Diego Healthcare System. He is the San Diego principal investigator
(PI) on a multisite National Institutes of Mental Health
grant assessing medication and psychotherapeutic interventions to individuals with complicated grief. He
served as advisor to the American Psychiatry Association’s Mood Disorders Task Force for DSM-5.
254 | Healio.com/Psychiatry
M. Katherine Shear, MD, is
Marion E. Kenworthy Professor
of Psychiatry at Columbia University School of Social Work.
She has served as co-chair of
the American Psychiatric Association Treatment Guidelines for
Panic Disorder, as Chair of the
Annual meeting of the Anxiety Disorders Association of America, and President of the Association for
Clinical Psychosocial Research. Her recent research
focuses in the area of bereavement and grief. Currently,
Dr Shear is overall PI of a 4-site National Institutes of
Mental Health study on treatment of complicated grief.
PSYCHIATRIC ANNALS 43:6 | JUNE 2013