Is DSM-IV Bereavement Exclusion for Major Depression Relevant to Treatment Response? A Case-Control, Prospective Study

Objective: The aim of the bereavement exclusion criterion for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) major depressive episode (MDE) is to identify subjects with a modest, self-limited, “normal” depressive syndrome. One would therefore expect less severe depressive symptoms and a different and better outcome for bereaved subjects who were excluded from the diagnosis of MDE as compared to MDE controls. In a previous cross-sectional study, we have shown such expectations were not met. Herein, we further challenge the accuracy of the bereavement exclusion criterion regarding response to treatment.

Method: In a database of 12,615 subjects seeking treatment for depression, 1,138 (9.0%) individuals met DSM-IV MDE criteria except the bereavement exclusion criterion. This sample was matched for age, gender, educational level, and number of previous depressive episodes with 1,138 MDE patients. The bereavement exclusion and MDE groups were prospectively assessed for outcome after 6 weeks of treatment. Primary outcome measures included the number of DSM-IV MDE symptoms and the presence/absence of DSM-IV MDE Criterion A symptoms at follow-up.

Results: The bereavement exclusion individuals had higher levels of DSM-IV MDE symptoms (P = .005) and self-rated depression (P < .0001) than MDE controls. Both groups had a similar 6-week outcome: 37.7% versus 39.9%, respectively, were responders to treatment, and 80.1% versus 82.2% no longer had the MDE DSM-IV symptom criteria at follow-up (P = .33).

Conclusions: The DSM-IV bereavement exclusion for MDE is inadequate according to response to treatment, at least in this sample of individuals seeking treatment for depressive symptoms. It is proposed that bereavement, just as any stressful event, could be noted but without its affecting the treatment decision.

J Clin Psychiatry 2011;72(7):898-902

Submitted: September 1, 2009; accepted January 1, 2010.

Online ahead of print: November 2, 2010 (doi:10.4088/JCP.09m05681blu).

Corresponding author: Emmanuelle Corruble, MD, PhD, Department of Psychiatry, Bicתtre University Hospital, 78 rue du General Leclerc-94275 Le Kremlin Bicתtre, France ([email protected]).