Line Between Bereavement and Major Depression Rightly Adjusted

You may have heard about an important change in how grief and depression can be diagnosed in the upcoming fifth edition of the Diagnostic and Statistical Manual (DSM-5), the book considered the “bible” for clinicians who diagnose psychiatric disorders. The change has received much attention in the professional and lay literature because it will significantly alter how clinicians can diagnose Major Depression. Unfortunately, much of the coverage of the new procedure fails to appreciate the clinical and empirical justifications for the change.

In classifying Major Depression, the DSM-5 removes the “bereavement clause,” which has prevented clinicians from diagnosing Major Depression until two months after, for instance, the death of family member. Using the DSM-5, clinicians will be able to diagnose Major Depression as early as two weeks after an event that triggered Bereavement. This change actually brings the DSM-5 in line with diagnostic criteria for Major Depression that were established in the ICD-10 (the international diagnostic text published by the World Health Organization) that has been used globally since 1992.

So, what’s the root of the controversy? Opponents of the change raise several important points. First, they believe that ordinary grief will be overdiagnosed as Major Depression and that grief could become an inviting target for drug companies. Second, they argue that Bereavement and Major Depression are different phenomena. Third, they suggest that it’s harmful to clients in their professional and personal lives to receive a diagnosis of Major Depression and that this change will mean that more people are diagnosed with Major Depression.

Fortunately, those on both sides of the debate are motivated by the same desire: wanting our clients to receive the best care in the face of universally-experienced grief (research shows that grief is not just a part of the human experience, but also is a part of the mammalian experience) and the very serious condition of Major Depression. No one on either side of the debate intends to pathologize normal grief. That said, it is important for those supporting the removal of the bereavement clause in the DSM-5 to defend the rationale behind the change.

The bereavement clause is based on the assumption that Bereavement and Major Depression are distinct psychological conditions. It is true that not everyone who is grieving experiences Major Depression. And certainly Major Depression results from many situations other than grief. However, there is no scientific evidence that bereavement-related depression is different from non-bereavement-related Major Depression in terms of severity, outcome,  course, treatment response, or comorbidity (i.e. the occurrence of a secondary condition that accompanies the diagnosed condition). In fact, research shows that bereavement-related depression is similar to depression occurring as a result of other losses on all these factors1-3. Removing the bereavement clause simply allows clinicians to appropriately treat individuals who have experienced loss and are experiencing Major Depression, which may or may not be related to the bereavement itself.

Major Depression is a severe condition and recovery outcomes improve significantly with early treatment–even just a couple of weeks can make a difference. Yes, some normal grief may be over-diagnosed as Major Depression; that risk is outweighed by the harm that can occur when Major Depression is missed or misdiagnosed. Drug companies are an easy target for opponents of this change to bring into the debate. However, isn’t it better that mental health treatment be based on science, rather than hypothetical concerns about what may happen regarding outside parties? Remember, clinicians always stand between drug companies and those seeking care. Finally, all mental health practitioners can agree that stigma accompanies being diagnosed with Major Depression. The truth is, there are many psychological conditions that carry stigma. That’s an unfortunate reality of our culture and does not stem from the practice of medicine, psychology, or any credible mental health practice itself. Health care professionals would do well to continue advocating for causes that seek to reduce and remove the stigmas associated with mental illness, rather than not give meaningful diagnoses when warranted. Diagnosis does actually open doors to treatment and positive outcomes.

Removing the bereavement clause simply gives clinicians and their clients more options and allows treatment to be more carefully and skillfully tailored to the individual case. This change will actually help normalize the experience of Major Depression and encourage people who are severely depressed and grieving to seek care sooner rather than later. Of course, psychotherapy can (and should) remain the leading treatment for brief and mild-to-moderate depression.

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1. Corruble E, Chouinard VA, Letierce A, et al. Is DSM-IV bereavement exclusion for major depressive episode relevant to severity and pattern of symptoms? A case-control, cross-sectional study. Journal of Clinical Psychiatry. 2009 Aug;70(8):1091-7.

2.Zisook S, Kendler KS: Is bereavement-related depression different than non-bereavement-related depression. Psychological Medicine: 1-31, 2007

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