Nearly every person has suffered the death a loved one. And, in nearly every case, the people left behind experience intense sadness, feelings of loss, an inability to concentrate, crying, and sleeplessness. In other words: grief. The debate surrounding revisions to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) from the American Psychiatric Association (APA) questions whether this grief is a normal human process or a mental disorder that requires diagnosis and treatment.

The current edition of the manual, the DSM-IV, excludes bereavement from the diagnosis of major depression, recognizing that symptoms that look like depression are a normal part of human emotion and behavior following the death of a loved one. However, the bereavement exclusion is expected to be removed from the DSM-V, which is scheduled for publication in May 2013. If this is the case, anyone experiencing normal symptoms of grief two weeks after the loss of a loved one can be diagnosed with and treated for depression.

Many clinicians and experts are weighing in on the exclusion — both for and against — citing research, clinical practice, and personal experience. An editorial in a recent edition of the Lancet cautions that eliminating the bereavement exclusion will medicalize grief and legitimize treatment with antidepressants, which the author believes is diagnostically simplistic and flawed, citing a lack of evidence for effectively treating bereaved people with antidepressants. The Lancet does support the APA’s claim that bereavement is associated with adverse health outcomes, but mostly in individuals who are already at risk for developing depression or whose normal, acute grief progresses to chronic, complicated grief. The same edition of the Lancet includes poignant and moving essays from clinicians describing their own personal experiences with grief and bereavement.

On the other side of the argument, the February edition of World Psychiatry includes an editorial in support of eliminating the bereavement exclusion from the DSM-V. First, the author notes that the DSM-IV does not totally exclude bereavement from the diagnosis of depression, it simply changes the threshold for diagnosis, requiring longer symptom duration, more substantial functional impairment, and the presence of specific symptoms. This approach reduces the likelihood of false positive diagnoses of major depression and avoids the trivialization of a mental disorder, according to the editorial. Several studies evaluating the similarities and differences in bereavement-related depression and depression related to other life events support the claim that there is no significant difference in characteristics of the two classifications, and that bereavement should be noted in the diagnosis of depression, but bereavement should not affect treatment.

Everyone experiences grief differently, and the grief associated with bereavement is shaped by the strength of relationship with the person who died, gender, religious beliefs, cultural context, and societal expectations. It is a necessary response to the loss of a loved one and part of the human experience. Normally, grief does not require medical intervention. But, in some cases, acute grief can morph into chronic, debilitating grief consistent with a major depressive disorder. Bereavement, and any other major life event or catastrophe, can act as a stressor and trigger the onset or worsening of physical and mental disorders. Regardless of the revised DSM-V criteria, clinicians should take caution to avoid under- and over-diagnosing depression in bereaved individuals and include compassion and empathy as the cornerstone of effective therapy.

References

Corruble E, Falissard B, & Gorwood P (2011). Is DSM-IV bereavement exclusion for major depression relevant to treatment response? A case-control, prospective study. The Journal of clinical psychiatry, 72 (7), 898-902 PMID: 21208577

Kendler KS, Myers J, & Zisook S (2008). Does bereavement-related major depression differ from major depression associated with other stressful life events? The American journal of psychiatry, 165 (11), 1449-55 PMID: 18708488

The Lancet, . (2012). Living with grief The Lancet, 379 (9816) DOI: 10.1016/S0140-6736(12)60248-7

Maj M (2012). Bereavement-related depression in the DSM-5 and ICD-11. World psychiatry : official journal of the World Psychiatric Association (WPA), 11 (1), 1-2 PMID: 22294995

Shear MK, Simon N, Wall M, Zisook S, Neimeyer R, Duan N, Reynolds C, Lebowitz B, Sung S, Ghesquiere A, Gorscak B, Clayton P, Ito M, Nakajima S, Konishi T, Melhem N, Meert K, Schiff M, O’Connor MF, First M, Sareen J, Bolton J, Skritskaya N, Mancini AD, & Keshaviah A (2011). Complicated grief and related bereavement issues for DSM-5. Depression and anxiety, 28 (2), 103-17 PMID: 21284063

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