Depressed or Bereaved? (Part 2)

By Neuroskeptic | March 20, 2011 6:52 pm

In Part 1, I discussed a paper by Jerome Wakefield examining the issue of where to draw the line between normal grief and clinical depression.


The line moved in the American Psychiatric Association’s DSM diagnostic system when the previous DSM-III edition was replaced by the current DSM-IV. Specifically, the “bereavement exclusion” was made narrower.

The bereavement exclusion says that you shouldn’t diagnose depression in someone whose “depressive” symptoms are a result of grief – unless they’re particularly severe or prolonged when you should. DSM-IV lowered the bar for “severe” and “prolonged”, thus making grief more likely to be classed as depression. Wakefield argued that the change made things worse.

But DSM-V is on its way soon. The draft was put up online in 2010, and it turns out that depression is to have no bereavement exclusion at all. Grief can be diagnosed as depression in exactly the same way as depressive symptoms which come out of the blue.

The draft itself offered just one sentence by way of justification for this. However, big cheese psychiatrist Kenneth S. Kendler recently posted a brief note defending the decision. Wakefield has just published a rather longer paper in response.

Wakefield starts off with a bit of scholarly kung-fu. Kendler says that the precursors to the modern DSM, the 1972 Feighner and 1975 RDC criteria, didn’t have a bereavement clause for depression either. But they did – albeit not in the criteria themselves, but in the accompanying how-to manuals; the criteria themselves weren’t meant to be self-contained, unlike the DSM. Ouch! And so on.

Kendler’s sole substantive argument against the exclusion is that it is “not logically defensible” to exclude depression induced by bereavement, if we don’t have a similar provision for depression following other severe loss or traumatic events, like becoming unemployed or being diagnosed with cancer.

Wakefield responds that, yes, he has long made exactly that point, and that in his view we should take the context into account, rather than just looking at the symptoms, in grief and many other cases. However, as he points out, it is better to do this for one class of events (bereavement), than for none at all. He quotes Emerson’s famous warning that “A foolish consistency is the hobgoblin of little minds”. It’s better to be partly right, than consistently wrong.

Personally, I’m sympathetic to Wakefield’s argument that the bereavement exclusion should be extended to cover non-bereavement events, but I’m also concerned that this could lead to underdiagnosis if it relied too much on self-report.

The problem is that depression usually feels like it’s been caused by something that’s happened, but this doesn’t mean it was; one of the most insidious features of depression is that it makes things seem much worse than they actually are, so it seems like the depression is an appropriate reaction to real difficulties, when to anyone else, or to yourself looking back on it after recovery, it was completely out of proportion. So it’s a tricky one.

Anyway, back to bereavement; Kendler curiously ends up by agreeing that there ought to be a bereavement clause – in practice. He says that just because someone meets criteria for depression does not mean we have to treat them:

…diagnosis in psychiatry as in the rest of medicine provides the possibility but by no means the requirement that treatment be initiated … a good psychiatrist, on seeing an individual with major depression after bereavement, would start with a diagnostic evaluation.

If the criteria for major depression are met, then he or she would then have the opportunity to assess whether a conservative watch and wait approach is indicated or whether, because of suicidal ideation, major role impairment or a substantial clinical worsening the benefits of treatment outweigh the limitations.

The final sentence is lifted almost word for word from the current bereavement clause, so this seems to be an admission that the exclusion is, after all, valid, as part of the clinical decision-making process, rather than the diagnostic system.

OK, but as Wakefield points out, why misdiagnose people if you can help it? It seems to be tempting fate. Kendler says that a “good psychiatrist” wouldn’t treat normal, uncomplicated bereavement as depression. But what about the bad ones? Why on earth would you deliberately make your system such that good psychiatrists would ignore it?

More importantly, scrapping the bereavement criterion would render the whole concept of Major Depression meaningless. Almost everyone suffers grief at some point in their lives. Already, 40% of people meet criteria for depression by age 32, and that’s with a bereavement exclusion.

Scrap it and, I don’t know, 80% will meet criteria by that age – so the criteria will be useless as a guide to identifying the people who actually have depression as opposed to the ones who have just suffered grief. We’re already not far off that point, but this would really take the biscuit.

ResearchBlogging.orgWakefield JC (2011) Should Uncomplicated Bereavement-Related Depression Be Reclassified as a Disorder in the DSM-5? The Journal of nervous and mental disease, 199 (3), 203-8 PMID: 21346493

  • Anonymous

    Here's another related recent in-press article by Kendler, though I am not sure it helps clarify things any – http://www.ncbi.nlm.nih.gov/pubmed/21383746 .

  • Anonymous

    Ah, OK let me get this straight: Major Depression ONLY occurs in the absence of a reactive (aka life stressor)? Gimme a break. This is bullshit.

  • http://www.blogger.com/profile/01737574572645126994 -p.

    Since this is Neuroskeptic and not Psycheskeptic, the question really should be whether depression and grieving can be distinguished as brain states (in whatever terms, from physiology to anatomy to observed behavior).

    Is there any evidence that grief-related sadness is different, anatomically or physiologically or whathaveyou, from depression? Or that grief at 4 weeks is distinguishable from depression, objectively, but at 8 weeks or 18 months, it's not? Or that the effective treatments for depression (which presumably modify an abnormal brain state) are ineffective for grief?

    The question of reasons and triggers for depression is horribly complicated and recursive. Scratch the surface, and you're into the social construction of illness. Short version being: depression is sadness we don't understand or can't explain (except to label it as “depression”), while grief (among other causes) is sadness we can account for in terms external to the person experiencing it.

    Inasmuch as depression and grief are similar experiences, and therefore (presumably?) similar brain states, there's no obvious reason why SSRIs (for instance) couldn't be offered to grieving people right from day 1.

    Of course it's a lot simpler to separate depression and grief based on their social context: grief is expected and understood and socially supported, while depression is none of those (except insofar as the diagnosis of “depression” becomes socially accepted). That's what the DSM is doing, defining when grief goes on “too long” to be fully explained by the exogenous situation.

    But then you're left with the uncomfortable realization that we're giving SSRIs to people mostly because (or at least, when) people around them don't understand why they're sad, or think they should be over it already. Which is a long way from neuroscience.

  • http://www.blogger.com/profile/06647064768789308157 Neuroskeptic

    -p : All good points. Frankly we don't have many answers there because all of the research goes into DSM-IV “Major Depression” which could include anything from very-slightly-complicated grief, to reactions to events, to “endogenous” depression, or any combination thereof.

    There's no money in researching sadness per se.

  • http://www.blogger.com/profile/16203083806436919715 Bernard Carroll

    Our ideas on the relatedness of grief and depression are informed by the reports of patients. I recall patients whom I treated through recurrent episodes of major depression over several years and who eventually experienced a bereavement. They insisted that their inner experience in bereavement differed from their past depressive episodes, both qualitatively and functionally. In bereavement, painful sadness and loss were dominant whereas in depression anhedonia and suicidal despair were in the foreground. I managed these bereaved states through our relationship, not by changing the medications.

    Patients like these are the prototypes who can shape our nosology. These are the patients who led to the adoption of 'distinct quality of depressed mood' as a characteristic of melancholia.

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About Neuroskeptic

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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