Depressed Or Bereaved? (Part 1)

By Neuroskeptic | March 10, 2011 7:18 pm

Part 2 is now out here.

My cat died on Tuesday. She may have been a manipulative psychopath, but she was a likeable one. She was 18.On that note, here’s a paper about bereavement.

It’s been recognized since forever that clinical depression is similar, in many ways, to the experience of grief. Freud wrote about it in 1917, and it was an ancient idea even then. So psychiatrists have long thought that symptoms, which would indicate depression in someone who wasn’t bereaved, can be quite normal and healthy as a response to the loss of a loved one. You can’t go around diagnosing depression purely on the basis of the symptoms, out of context.

On the other hand, sometimes grief does become pathological – it triggers depression. So equally, you can’t just decide to never diagnose depression in the bereaved. How do you tell the difference between “normal” and “complicated” grief, though? This is where opinions differ.

Jerome Wakefield (of Loss of Sadness fame) and colleagues compared two methods. They looked at the NCS survey of the American population, and took everyone who’d suffered a possible depressive episode following bereavement. There were 156 of these.

They then divided these cases into “complicated” grief (depression) vs “uncomplicated” grief, first using the older DSM-III-R criteria, and then with the current DSM-IV ones. Both have a bereavement exclusion for the depression criteria – don’t diagnose depression if it’s bereavement – but they also have criteria for complicated grief which is depression, exclusions to the exclusion.

The systems differ in two major ways: the older criteria were ambiguous but at the time, they were generally interpreted to mean that you needed to have two features out of a possible five; prolonged duration was one of the list and anything over 12 months was considered “prolonged”. In DSM-IV, however, you only need one criterion, and anything over 2 months is prolonged.

What happened? DSM-IV classified many more cases as complicated than the older criteria – 80% vs 45%. That’s no surprise there because the criteria are obviously a lot broader. But which was better? In order to evaluate them, they compared the “complicated” vs “normal” episodes on six hallmarks of clinical depression – melancholic features, seeking medical treatment, etc.

They found that “complicated” cases were more severe under both criteria but the difference was much more clear cut using DSM-III-R.

Wakefield et al are not saying that the DSM-III-R criteria were perfect. However, it was better at identifying the severe cases than the DSM-IV, which is worrying because DSM-IV was meant to be an improvement on the old system.

Hang on though. DSM-V is coming soon. Are they planning to put things back to how they were, or invent an even better system? No. They’re planning to, er, get rid of the bereavement criteria altogether and treat bereavement just like non-bereavement. Seriously. In other words they are planning to diagnose depression purely on the basis of the symptoms, out of context.

Which is so crazy that Wakefield has written another paper all about it (he’s been busy recently), which I’m going to cover in an upcoming post. So stay tuned.

ResearchBlogging.orgWakefield JC, Schmitz MF, & Baer JC (2011). Did narrowing the major depression bereavement exclusion from DSM-III-R to DSM-IV increase validity? The Journal of nervous and mental disease, 199 (2), 66-73 PMID: 21278534

CATEGORIZED UNDER: 1in4, freud, mental health, papers, surveys
  • pj

    I guess that highlights why it is good that clinical practice doesn't always track these diagnostic fads.

    The change from DSM-III to DSM-IV to DSM-V wouldn't massively change my clinical practice anyway (since we use ICD-10 in the UK*) but things like assessing whether bereavement is 'atypical' are still very much clinical judgements that don't necessarily come down to a simple box ticking exercise.

    * This tends to put grief reactions under the 'adjustment disorder' category.

  • flora_mundi

    i sometimes think that dsm updates represent thought trends of their time rather than improvements.

    and as someone who lost an 18 year old cat a few years ago- my closest companion for half my life- i'm sorry for the loss of your feline friend.

  • antianticamper

    I'm very sorry for your loss.

  • Tiel Aisha Ansari

    Sorry to hear about your cat. My old cat died three years ago: I still miss him.

  • Anonymous

    When are we going to realize that Mother Nature cares nothing for our nosologigcal system?

  • Kapitano

    There's a kind of sadness that comes from losing something you love, and we call it grief.

    But there's another kind which seems to me very similar – the sadness that comes with being uprooted in an unfamiliar city or country.

    And there's a third kind, which you see when someone loses their job, gets a divorce or falls from a position of power.

    We might call these by different names, but I think these are all really the same feeling, prompted by what is at heart the same thing: Loss of something you've depended on in some way for a long time – even when you didn't realise you were depending on it.

    Perhaps the grief of berevement shouldn't be put in its own box.

  • veri

    Neo, there's no need to be depressed, she wouldn't want that.

    When I was little I had a cat. There were times I used to sit in my tree house alone and weep. But she'd always, always be in that tree house with me. Of all the tears I've shed in my life, my cat witnessed most of them. After cuddling and talking to her, I could stand up and face the world again. I would've been alone as a kid if it wasn't for her. She was like an angel to me.

    Eighteen years is a long time, longer than most marriages. I don't think words do justice in describing what it's like to love and commit to someone/pets so much and then lose them. Perhaps some things are meant to be felt only by the heart, and left to heal in the heart, which of course needs time. My condolences.

  • Neuroskeptic

    Kapitano: Funny you should say that. I agree with you but this is actually the justification the DSM-V team give for taking out the bereavement criterion : they say that it's inconsistent to treat bereavement differently from other forms of sadness.

    Which is quite true, however, their proposed solution puts consistency over common sense, and solves the problem of something being not very good, by making it much worse.

  • Retriever

    So sorry about your cat. My 18 year old half-Siamese cat died last week, and have been shattered, despite telling myself it was a “merciful release” for her.

    Good post about the depression/bereavement. I remember particularly a woman hospitalized six months after 9/11 because her family felt that she was taking “too long” to get over her young son (a young broker) incinerated in one of the upper stories of the World Trade Center. She showed me picture after picture of him alive and would become animated talking about his interests, then would sink back into near catatonia. Complicated mourning. Probably a combination of a predisposition to depression, and the horrible shock (who would not become depressed after seeing the films of the people jumping from the towers and wondering if your loved one was one of them or was just burned up in agony??)

  • Anonymous

    DSM-V is going to exclude bereavement because they ran into a bit of a conundrum: Why stop at bereavement after the loss of a loved one? Why not include all significant losses? Like of a job. Or a limb. Or health in general. Maybe even hair. Perhaps virility. Or an illusion about the self? Or a house? Or, perhaps, even a cat. The list of “reactive” losses is endless. This is just another attempt by biological psychiatry to remove environmental influences on mood states in an effort to push more product (aka drugs). EVERYTHING IS MAJOR DEPRESSION! It is stupid and intellectually dishonest.

  • Anonymous

    Here's their defense/rationale for it – .

  • Neuroskeptic

    Anonymous: Yeah that's what Wakefield responded to in his latest piece; I'm covering it in the upcoming post.

  • Anonymous

    The first-hand experience is enough to tell me the difference. I've suffered bereavement, I suffer/live with depression. It's noticeably different!!!

    I'm still yet to meet a psychiatrist who can talk about the dividing line to be frank. It gets confusing!

  • Anonymous

    A Neuroscientist sent this to me. Seems like you can you use it more than I could @ the moment.

  • Emmy

    Well, I find this especially interesting. So far as I know, science does not even fully understand our relationship with our pets, much less understand how we grieve when they die. Anthropologist Pat Shipman's hypothesis

    scratches the surface but it's still not fully understood unless you buy into some silly new-age view of “fur babies” (yikes).

    Another mystery is that many pet owners feel a strange and overwhelming sense of guilt when their pet dies, even when it's from something uncontrollable like cancer. Anyway, they say the last gift we give to our pets is grieving for them. That made me feel better when we lost our cat, hope it does for you as well.



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Neuroskeptic is a British neuroscientist who takes a skeptical look at his own field, and beyond. His blog offers a look at the latest developments in neuroscience, psychiatry and psychology through a critical lens.


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