American Society of Clinical Psychopharmacology Corner
J Craig Nelson MD, Editor
Bereavement, Complicated Grief, and DSM, Part 1: Depression
To spare oneself from grief at all costs can be achieved only at the price of total detachment, which excludes the ability to experience happiness.
The Case of Mr A
Mr A is a 73-year-old man whose wife of 50 years died 5 weeks previously. He has no appetite, has lost 8 lb in the past month, consistently awakens at 4 am, "can’ t think straight," and no longer takes any pleasure in customary activities. He denies feelings of guilt or worthlessness. Although he denies suicidal intent, he confides that he wishes to join his dearly departed wife. When discussing his wife, he shows moderate psychomotor agitation and spends most days mindlessly sitting in front of his television.
According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR),1 Mr A does not have a psychiatric condition; consequently, treatment with antidepressants or formal psychotherapy is not indicated. Mr A would be assigned the V-code, bereavement, and reassured that nothing is wrong. However, according to the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10),2 Mr A has major depressive disorder (MDD). Ostensibly, decisions about treatment would be made just as they would after any other, non-bereavement-related, episode of MDD. The question to be addressed in the following discussion is whether the best available evidence more strongly supports the DSM-IV-TR or the ICD-10.
History of the DSM Bereavement Exclusion
Prior to the 1980 publication of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III),3 bereavement was not part of psychiatry’s official nomenclature. DSM-III introduced recent bereavement as an exclusion for the diagnosis of major depressive episode (MDE) and as a V-code (other conditions that may be a focus of clinical attention but are not themselves instances of mental disorders):
As part of their reaction to the loss, some grieving individuals present with symptoms characteristic of a MDE.’ ¦the duration and expression of "normal" bereavement vary considerably among different cultural groups.’ ¦the diagnosis of Major Depressive Disorder (MDD) is generally not given unless the symptoms are still present 2 months after the loss’ ¦however, the presence of certain symptoms (guilt, suicidal thoughts, worthlessness, psychomotor retardation, marked functional impairment and psychotic features) that are not characteristic of a "normal" grief reaction may be helpful in differentiating bereavement from a MDE (pp 40-41).
Thus, according to the DSM-IV-TR, an individual who meets all symptomatic, duration, and impairment criteria for MDD but is recently bereaved may not have MDD; in contrast, a nonbereaved individual with the same clinical constellation of symptoms who is recently divorced, impoverished, or disabled or who cannot identify any recent adversity does have MDD. Does the preponderance of available data support this distinction?
In the most current DSM edition, DSM-IV-TR, bereavement remains an exclusion for the diagnosis of MDE and continues as a V-code, but bereavement is also mentioned as an exclusion for the diagnosis of adjustment disorder and, under certain circumstances, for the diagnosis of posttraumatic stress disorder (PTSD). Of interest, the ICD-10 does not exclude the diagnosis of MDE or adjustment disorder based on recent bereavement and does not have a V-code for bereavement. That there are differences in the ways the DSM-IV-TR and the ICD-10 deal with the nosologic status of bereavement speaks to uncertainty, disagreement among "experts," and the lack of reliable data to guide diagnostic and treatment decisions in the context of bereavement. Given that one of the goals of the DSM-V development committees is to better align diagnostic criteria with ICD-10 and ICD-11, the time has come to evaluate relevant evidence for and against present diagnostic conventions and to make changes based on the best available evidence. This 2-part series focuses on the 2 most controversial issues regarding the role of bereavement in psychiatric diagnoses. Part 1 focuses on the question, Should the recent death of a loved one continue to exclude the diagnosis of MDE? and part 2 focuses on the question, Is there a point at which grief fails to be adaptive and should be diagnosed as a clinical condition requiring formal treatment? The authors will conclude with recommendations for DSM-V based on the best available data.
Bereavement and Depression
Bereavement is a universal stressor that is one of the most likely to precipitate an episode of major depression.4,5 Studies show that approximately one-third of all widows or widowers manifest a full major depressive episode 1 month after the death of a spouse; approximately one-fourth, at 7 months; approximately 15%, at 1 and 2 years; and up to 10% may meet criteria for MDE for the entire year.6-8 Yet, many clinicians are confused by the relationship between grief and depression and are uncertain about when to make the diagnosis of MDE in bereaved individuals. The principal source of diagnostic confusion is the common occurrence of low mood, sadness, and social withdrawal in both bereavement and MDE. The DSM-III and its subsequent iterations have attempted to prevent overdiagnosis of MDD in bereaved persons who are sad and withdrawn by excluding recently (less than 2 months after the death) and acutely (duration less than 2 months) bereaved individuals from the diagnosis of MDE unless they also meet certain other conditional criteria (worthlessness, psychomotor retardation, suicidal ideation, psychotic features, severe distress or dysfunction). However, many grief experts, rather than considering a full major depressive syndrome in the context of grief to be "normal," question the DSM-IV-TR convention of waiting a full 2 months before making the diagnosis.
The bereavement exclusion was originally introduced immediately after publication of a series of reports by Clayton et al7,8 documenting the high prevalence of major depressive syndromes occurring during bereavement. Because these depressive syndromes tended to be relatively mild, usually dissipated over time without treatment, and "differed" from clinical depression in several ways, Clayton cautioned against overdiagnosing major depression during the first year of bereavement. Since then, however, 2 reviews6,9 have noted the similarities between bereavement-related depressive syndromes and other non-bereavement-related MDD in terms of clinical and biologic characteristics, common comorbidities, course, and treatment response. In addition, 3 secondary analyses of large population-based databases10-12 have demonstrated similarities between bereavement-related major depressive syndrome and other life-event-related depressions with respect to demographic and clinical characteristics, intensity, familiality, course, associated features, and treatment responses. In addition, in a large population-based prospective study, Karam et al13 reported that the global symptom profile of depressed individuals and their risk for depressive recurrence were similar in bereaved and nonbereaved subjects, and the duration of illness was actually longer in the bereaved group. Further, in a large, case-control, cross-sectional study of a national database, Corruble et al14 found that subjects who are excluded from the diagnosis of MDE on the basis of current DSM-IV-TR conventions are, if anything, even more severely depressed than MDD controls without bereavement. None of these reviews or studies provides support for the special treatment given to bereavement-related depression in the DSM. The conclusion is either that all depressive episodes that occur soon after a stressful life event and are not associated with the conditional features of morbid feelings of worthlessness, psychomotor retardation, suicidal ideation, psychotic features, or marked and prolonged functional impairment should not be given the diagnosis of MDE (the position of Wakefield et al10) or that the bereavement exclusion should be eliminated from the DSM-V (the conclusion of Zisook and Kendler,6 Zisook et al,9 Kendler et al,11 Kessing et al,12 Karam,13 Corruble et al,14 and possibly Clayton8).
Returning to the Case of Mr A
The preponderance of available evidence supports the ICD-10 convention of diagnosing MDD when all symptomatic, duration, and severity criteria are met. It does not support the exclusivity of bereavement as the only life event that negates the diagnosis of MDD. Mr A would be ill-served if his MDD were "explained away" by his grief and if he were thereby denied the best available treatment for his depression.
Recommendations for DSM-V
On the basis of the best available data as briefly reviewed in this article, we recommend that DSM-V:
1. Eliminate the bereavement exclusion for the diagnosis of MDD.
2. Either eliminate the V-code bereavement or specify that it should not be used when symptoms can be better explained by MDD, adjustment disorder (space does not permit discussion of why we believe the bereavement exclusion for adjustment disorder also should be eliminated), PTSD, or complicated grief. More useful than the V-code as now conceived would be a fuller description of uncomplicated grief and of the phenomenological distinctions between the dysphoria associated with grief and with major depression.15
Author affiliations: Department of Psychiatry, University of California San Diego (Drs Zisook and Lebowitz); Department of Psychiatry, San Diego VA Healthcare System, California (Drs Zisook and Tal-Young and Ms Madowitz); Department of Psychiatry, University of Pittsburgh School of Medicine; and Department of Community and Behavioral Health Science, University of Pittsburgh Graduate School of Public Health, Western Psychiatric Institute and Clinic, Pennsylvania (Dr Reynolds); Department of Psychiatry, Tufts University School of Medicine, Boston, Massachusetts (Dr Pies); Department of Psychiatry, Harvard Medical School, Boston, Massachusetts (Dr Simon); and Columbia University School of Social Work and Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York (Dr Shear). Potential conflicts of interest: Dr Zisook has received grant/research support from Pamlab and honoraria from GlaxoSmithKline. In the last 12 months, Dr Simon has received grant/research support from American Foundation for Suicide Prevention, Forest, and National Institute of Mental Health and has been a speaker (CME) for Pfizer. Drs Reynolds, Pies, Lebowitz, Tal-Young, and Shear and Ms Madowitz report no financial or other relationships relevant to the subject of this article. Funding/support: This work was supported by National Institute of Mental Health grants R01 MH08529701A1 and R01 MH085308-1, a grant from the American Foundation for Suicide Prevention, and the John A. Majda, MD, Memorial Foundation. Corresponding author: Sidney Zisook, MD, Department of Psychiatry, University of California San Diego, 9500 Gilman Dr 0603-R, La Jolla, CA 92093-0603 ([email protected]).
References
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.
2. World Health Organization. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. http://www.who.int/classifications/icd/en/. Accessibility verified June 4, 2010.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Third Edition. Washington, DC: American Psychiatric Association; 1980.
4. Shear MK, Clayton PJ. Bereavement-related depression. Psychiatr Ann. 2008;38(10):643-646. doi:10.3928/00485713-20081001-03
5. Zisook S, Paulus M, Shuchter SR, et al. The many faces of depression following spousal bereavement. J Affect Disord. 1997;45(1-2):85-94, discussion 94-95.PubMed doi:10.1016/S0165-0327(97)00062-1
6. Zisook S, Kendler KS. Is bereavement-related depression different than non-bereavement-related depression? Psychol Med. 2007;37(6):779-794. PubMed
7. Clayton PJ, Desmarais L, Winokur G. A study of normal bereavement. Am J Psychiatry. 1968;125(2):168-178. PubMed
8. Clayton PJ. V code for bereavement. J Clin Psychiatry. 2010;71(3):359-360.PubMed doi:10.4088/JCP.09lr05646blu
9. 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. PubMed
10. Wakefield JC, Schmitz MF, First MB, et al. Extending the bereavement exclusion for major depression to other losses: evidence from the National Comorbidity Survey. Arch Gen Psychiatry. 2007;64(4):433-440.PubMed doi:10.1001/archpsyc.64.4.433
11. Kendler KS, Myers J, Zisook S. Does bereavement-related major depression differ from major depression associated with other stressful life events? Am J Psychiatry. 2008;165(11):1449-1455. PubMed doi:10.1176/appi.ajp.2008.07111757
12. Kessing LV, Bukh JD, Bock C, et al. Does bereavement-related first episode depression differ from other kinds of first depressions? [published online ahead of print August 20, 2009] Soc Psychiatry Psychiatr Epidemiol. doi:10.1007/s00127-009-0121-6 PubMed
13. Karam EG, Tabet CC, Alam D, et al. Bereavement related and non-bereavement related depressions: a comparative field study. J Affect Disord. 2009;112(1-3):102-110.PubMed doi:10.1016/j.jad.2008.03.016
14. 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. J Clin Psychiatry. 2009;70(8):1091-1097.PubMed doi:10.4088/JCP.08m04475
15. Lamb K, Pies R, Zisook S. The bereavement exclusion for the diagnosis of major depression. Psychiatry. In press.
doi:10.4088/JCP.10ac06303blu
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