Nearly 2.5 million Americans die each year, leaving behind an even larger group of grief-stricken people. Such a universal human experience as grief is recognized by the lay public and medical professionals alike as an entirely normal and expected emotional response to loss. Clinicians and researchers have long known that, for the vast majority of people, grief typically runs its course within 2 to 6 months and requires no treatment.
In a common clinical scenario, a patient who has just lost a loved one presents to a physician with mild depressive symptoms, such as sadness, tearfulness, and insomnia. Under the guidelines of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), a practitioner would reasonably view these depressive symptoms as grief-related and not diagnose clinical depression: the depressive symptoms are mild and have lasted less than 2 months. A clinician can make a diagnosis of major depression even in the context of grief if the depressive symptoms are unrelenting or if the patient has severe impairment of functioning or delusional or suicidal thinking. (To receive a diagnosis of major depression according to the DSM-IV, a patient must have either depressed mood or loss of pleasure plus four or more associated symptoms – such as appetite loss, insomnia or hypersomnia, psychomotor change, fatigue, low self-esteem, diminished concentration, and recurrent thoughts of death or suicide – for at least a 2-week period.)
Admittedly, it can be challenging for many practitioners to tell the difference between acute grief and depression. Grief-stricken patients frequently report symptoms that are also typical of major depression, such as sadness, tearfulness, insomnia, and decreased appetite. But, as numerous researchers have noted, grief rarely produces the cognitive symptoms of depression, such as low self-esteem or feelings of worthlessness. And although bereaved patients may fantasize about being reunited with a lost loved one through death, they do not generally experience the explicit and persistent suicidal ideation typical of major depression.
Thus, the DSM-IV clearly distinguishes the normal and expected grief after loss from the more persistent and severe symptoms of clinical depression. And it does so for good reason: although uncomplicated grief can be painful, it is short-lived and benign, and it does not severely impair function or increase the risk of suicide as major depression does.
Now, however, the American Psychiatric Association is considering making a significant change to the definition of depression in the upcoming 5th edition of the DSM, which would specifically characterize bereavement as a depressive disorder. In removing the so-called bereavement exclusion, the DSM-5 would encourage clinicians to diagnose major depression in persons with normal bereavement after only 2 weeks of mild depressive symptoms. Unfortunately, the effect of this proposed change would be to medicalize normal grief and erroneously label healthy people with a psychiatric diagnosis. And it will no doubt be a boon to the pharmaceutical industry, because it will encourage unnecessary treatment with antidepressants and antipsychotics, both of which are increasingly used to treat depression and anxiety.
Nor will this change help practitioners deal with the common dilemma presented by the bereaved patient with mild depressive symptoms – the question of how to tell whether such a patient is heading toward major depression or should be left alone to grieve. The answer is often not clear after a first visit, in which case a period of watchful waiting is reasonable. If the symptoms persist or intensify, a diagnosis of clinical depression becomes more likely.
This problem, I believe, is at the heart of the controversy about redefining the diagnostic criteria for depression in the upcoming DSM-5. The experts who favor the change are concerned that some bereaved patients who need psychiatric treatment will go without it because their depressive symptoms will be reflexively attributed to their grief under the bereavement exclusion.
The concern is understandable, particularly in light of the fact that only 50% of people with major depression in the general population and 33% of patients with major depression in the primary care setting receive any treatment for depression.3 But the argument that there is no essential difference between grief-related depression and clear-cut major depression is contradicted by rigorous data. For example, a study using data from the National Epidemiologic Survey on Alcohol and Related Conditions showed that persons who had a bereavement-related depressive syndrome at baseline were no more likely over a 3-year follow-up period to have a major depressive episode than those who had no lifetime history of major depression at baseline. In contrast, subjects who had had an episode of major depression at baseline were significantly more likely to have a recurrence of depression during the 3-year follow-up than those without a history of depression or those who had only had bereavement-related depression.
Thus, it seems clear that depressive symptoms in the context of grief are fundamentally different, in terms of course and prognosis, from those of clinical depression. But that does not mean that all grief goes smoothly or should be ignored by clinicians.
For example, bereaved persons with a history of major depression are obviously at high risk for depressive recurrence in the context of loss, as they would be in the face of numerous stressors, and they should be monitored closely for worsening neurovegetative symptoms or the emergence of suicidal or delusional thinking. We also know that 10 to 20% of bereaved people do not get over their grief easily and go on to develop a syndrome of complicated grief, characterized by an intense and persistent longing for the deceased, a sense of anger and disbelief over the death, and a disturbing preoccupation with the lost one.
But for most people, grief resolves naturally on its own. Because the vast majority of bereaved and clinically depressed patients are seen by primary care practitioners, it is critical that such practitioners be skilled at distinguishing between clinical depression, which requires treatment, and uncomplicated grief, which is an entirely normal emotional response to loss. The medical profession should normalize, not medicalize, grief.
Editor’s note: On May 9, 2012, the APA announced that although the bereavement exclusion will still be eliminated from the definition of major depression, a footnote will be added indicating that sadness with some mild depressive symptoms in the face of loss should not necessarily be viewed as major depression.
Disclosure forms provided by the author are available with the full text of this article at NEJM.org.
This article (10.1056/NEJMp1201794) was updated on May 17, 2012, at NEJM.org.
SOURCE INFORMATION
From the Department of Psychiatry, Weill Medical College of Cornell University, New York.
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Richard A. Friedman, M.D.
N Engl J Med 2012; 366:1855-1857