by Joye C. Anestis
When I teach undergraduates about mental illness, we always discuss the line between "normal" and "abnormal" behavior or reactions. One particular piece of diagnostic information always gets the topic really going. I show them the diagnostic criterion for Major Depression and point out this criterion: "the symptoms are not better counted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation" (APA, 2000). Inevitably, the students zoom in on the 2 month criterion, with questions like "What is the reasoning behind limiting grief reactions to 2 months?", "How can they put a time limit on grief?" Many are outraged at the supposed implication that it is abnormal for grief to persist after 2 months. This puts us into a discussion of "normal versus "abnormal" grief (where I clearly explain that the DSM is referring to a small group of people who have severe and persistent grief reactions)...and then into the general idea of delineating between normal and abnormal. I find it a really effective way to get them to think about all the nuances that go into a classification system like the DSM and the care that is taken when trying to make a diagnosis and help someone who is suffering.
Interestingly (and unfortunately for my future lectures), one of the proposed changes to DSM-5 is the removal of the bereavement criterion from the Major Depressive Episode symptom list. The rationale cited by the Task Force states: "the exclusion of symptoms judged better accounted for by Bereavement is removed because evidence does not support separation of loss of loved one from other stressors" (see it for yourself here). They cite a 2007 study by Zisook & Kendler as support for their rationale. I thought I'd check out the validity of this argument for myself. Zisook & Kendler conducted an exhaustive literature review and asked the question: "Is bereavement-related depression different than non-bereavement-related depression?" Unfortunately, the quality of the studies and the type of results reported by the studies prevented the authors from conducting a meta-analysis. And, unfortunately, no studies exist that specifically examine whether bereavement-related depression and standard (i.e., non-bereavement-related) depression are forms of the same disorder. The ideal study would compare individuals whose depression began within 2 months of the loss of a loved one who do not have any of the symptoms listed by the DSM-IV as uncharacteristic of normal grief (e.g., suicidality) with depressed individuals whose episodes are of similar duration and symptom profile but with an onset unrelated to the death of a loved one.
Keeping this in mind, the literature review revealed, overall, generous support for the hypothesis that bereavement-related depression is similar to standard depression. The authors note multiple points on which the 2 syndromes are similar. Both are occur at greater rates in individuals who are young, have personal or family history of depression, have poor social support, and have poor health. Clinical characteristics shared between the syndromes include: impaired functioning, comorbidity with anxiety disorders, feelings of worthlessness, psychomotor changes, and increased suicidality (interestingly, the last 3 are symptoms that the DSM-IV specifically notes are unlikely to occur in "normal" bereavement). The 2 syndromes also share several biological characteristics: increased adrenocortical activity, impaired immune function, and disrupted sleep architecture. Finally, the authors note that both are "common, long lasting, and recurrent" and both respond to antidepressant meds. The conclusion that they draw from this is that, considering what we know (and acknowledging that our knowledge is incomplete), the bereavement criterion seems unnecessary.In my opinion, many of the DSM-5 proposed changes trend towards being overinclusive (i.e., false positives) rather than risk missing individuals. There seems to be a philosophy that erring on the side of caution is the preferred course of action (consider hypersexual disorder). This may be one of those situations. Clearly there are individuals whose initial grief reactions are severe enough to warrant diagnosis and treatment, but adequate research has not been done to allow us to clearly demarcate between the groups. Zisook and Kendler (2007) do raise the interesting and (in my opinion) valid point that loss of a loved one is the only negative life event singled out in DSM-IV for diagnosticians to consider when excluding individuals. There is ample literature that negative life events commonly precede major depressive episodes, but we do not exclude individuals from receiving a depression diagnosis if the current episode is within 2 months of a divorce or job loss. Considering this, I'm inclined to agree with Zisook & Kendler, as well as the Mood Disorders Task Force, that perhaps a specific bereavement criteria is unwarranted.
Before I sign off, I do want to clarify the vast majority of bereaved people do not exhibit symptoms characteristics of major depression and do not exhibit long-term problems (Bonanno, 2004). In fact, there is evidence of a great deal of resilience in most people, even in the months directly following a loss (Bonanno et al., 2005; Bonanno et al., 2002; Bonanno et al., 2004). But a small subset of people (about 10-15%; Bonanno & Kaltman, 1999, 2001) do exhibit severe grief reactions...these are the folks who are the subject of debate. Is a 2-month waiting period appropriate, or should diagnosis and intervention be made available as early as possible?
Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.