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December 4, 2008 — Major depression related to bereavement is essentially identical to major depression brought on by other stressful life events, suggesting that it should not be excluded from standard depression diagnoses, new research suggests.

Currently, the Diagnostic and Statistical Manual of Mental Disorders, 4th ed (DSM-IV) assigns special status to bereavement-related depression, claiming it is distinct from all other depressive episodes. However, these latest findings challenge this assertion.

"Depression that occurs in the context of the loss of a loved one is essentially identical to depression that occurs in the context of any other negative event or loss," study coauthor Sidney Zisook, MD, from the University of California, San Diego, told Medscape Psychiatry.

The study, led by Kenneth S. Kendler, MD, from Virginia Commonwealth University Medical School, in Richmond, was published in the November issue of the American Journal of Psychiatry.

"If a bereaved person's depression otherwise meets criteria for major depression, it should be taken seriously, diagnosed as major depression, and treated accordingly, rather than continuing to use the bereavement-exclusion rule and treating this as 'normal grief,' " said Dr. Zisook.

Bereavement is the only predisposing stressful life event that is singled out in the DSM-IV. To determine the validity of distinguishing normal grief from major depression associated with other stressful life events, the researchers examined a large population-based sample of twins.

They identified 82 individuals with confirmed bereavement-related depression and 224 individuals with depression related to stressful life events, including divorce/separation (167), illness (36), and job loss (21).
Similarities Outweigh Differences

A total of 23 people (28%) with bereavement-related depression met the DSM-IV criteria for normal grief, but a similar proportion of people with depression unrelated to bereavement, 55 people (25%), also met these criteria.

"The 2 groups were similar in many important ways, including duration of the index episode, the frequency of severe impairment, [and] the clinical severity of the episode," the researchers report.

"The similarities of bereavement-related depression and depression related to other stressful life events far outweigh their differences. We were unable to show, as predicted by DSM, that cases of depression meeting criteria for both bereavement-related depression and 'normal grief' were unique in any way. On their face, these results argue against the continued use of the 'bereavement-exclusion rule' in the DSM-V," the authors write.

Treatment decisions depend on the severity and persistence of the depression, as well as the patient's history, so not every bereaved individual who meets the criteria for major depression needs to be treated with medications right away, said Dr. Zisook.

"But if the individual meets the criteria for major depression, you don't do him or her a favor by ignoring the symptoms and saying, 'Oh, that's just normal grief.' Unrecognized or untreated major depression can have serious consequences," he said.

Another Point of View

Investigators at New York University, led by Jerome C. Wakefield, PhD, DSW, also found many more similarities than differences between bereavement-related depression and depression related to other stressful life events (Arch Gen Psychiatry. 2007;64:433-440) but came to a "dramatically different" conclusion.
Instead of dropping the bereavement-exclusion rule, they suggest extending the exclusion to all episodes of uncomplicated life-event–precipitated depressive episodes.

"The bereavement exclusion is too narrow," Dr. Wakefield told Medscape Psychiatry. "It ought to be extended to cover similar not-too-long, not-too-severe reactions to other major stressors in life."
According to Dr. Wakefield, uncomplicated bereavement is clearly not disordered and looks similar to uncomplicated reactions to other stressors.

Opposite Proposals

In an accompanying editorial, Mario Maj, MD, from the University of Naples, in Italy, says that the conflicting recommendations by the 2 research groups are likely to be divisive.

"These opposite proposals based on the same research are likely to divide our field and the public opinion for several years," he writes.

"Of course, both proposals have significant treatment implications. On the one hand, the risk is to medicalize an adaptive response, thus disrupting the individual's coping processes. On the other, the risk is to deprive a person with full depressive syndrome of a treatment that may be needed."

Dr. Maj continues: "At the present state of knowledge, it may be therefore unwise to disallow the diagnosis of major depression in a person meeting the severity, duration, and impairment criteria for that diagnosis just because the depressive state occurs in the context of a significant life event."

"On the other hand, the removal of the bereavement-exclusion criterion from the DSM-V diagnosis of major depression — a move that may be perceived as a further step in psychiatry's attempt to pathologize normal human processes — requires strong and unequivocal research evidence," Dr. Maj notes.

However, Dr. Maj believes that before a decision to remove the bereavement-exclusion criterion from the future editions of the DSM is made, the results of the current study should be validated in various groups and scenarios — young vs old, impact of losing a close relative vs a friend, etc.


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