Can depression and bereavement overlap – or even co-exist?
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is a diagnostic tool used by mental health professionals, offering a common language and standard criteria for the classification of mental disorders.
The earlier edition (DSM-IV) contained an exclusion criterion called the bereavement exclusion, for a major depressive episode. This meant that a person could show the symptoms of depression but if it were within 2 months after the death of a loved one, it would not be diagnosed as depression. However, this exclusion was omitted in DSM-5 and has been cause for much debate among the Australian Psychological Society (APS), in part due to worry that the removal could lead to pathologising normal grief, over-diagnosis of depression and inappropriate use of medications.
Major Depressive Disorder and Bereavement Defined
The essential features of a major depressive disorder last for minimum period of two weeks, during which there is either depressed mood or the loss of interest or pleasure in nearly all activities. The individual must experience at least FOUR additional symptoms drawn from the following list:
- Change in appetite or weight;
- Change in sleep;
- Psychomotor agitation;
- Decreased energy;
- Feelings of worthlessness or guilt;
- Difficulty thinking, concentrating or making decisions;
- Recurrent thoughts of death or suicidal ideation or suicide plans or attempts.
These symptoms must persist for most of the day, nearly every day, for at least two consecutive weeks. The episode must be accompanied by clinically significant distress or impairment in social, occupational, or other important areas of functioning, and must not be attributable to the psychological effects of a substance or to another medical condition.
Like depression, the symptoms of bereavement (also referred to as grief) include a loss of appetite, increased irritability, difficulty sleeping and fatigue.
The main difference between depression and bereavement, is the intense yearning or longing for the deceased that is expressed by someone who is grieving. Bereavement can also be expressed through feelings of intense sorrow, emotional pain and a preoccupation with the deceased or the circumstances of the death.
What other changes to major depression disorder and bereavement were made?
The bereavement exclusion was replaced with a detailed footnote to aid clinicians in making the critical distinction between the symptoms characteristic of bereavement, and those of a major depressive episode.
- Major depressive disorder grief footnote: In distinguishing grief from a major depressive episode (MDE), it is useful to consider that in grief the predominant affect is feelings of emptiness and loss, while in a MDE it is persistent depressed mood and the inability to anticipate happiness or pleasure. The dysphoria in grief is likely to decrease in intensity over days to weeks and occurs in waves, the so-called pangs of grief. These waves tend to be associated with thoughts or reminders of the deceased.
- The depressed mood of MDE is more persistent and not tied to specific thoughts or preoccupations. The pain of grief may be accompanied by positive emotions and humour that are uncharacteristic of MDE. The thought content associated with grief generally features a preoccupation with thoughts and memories of the deceased, rather than the self critical or pessimistic ruminations seen in MDE. In grief, self esteem is generally preserved, whereas in MDE feelings of worthlessness and self-loathing are common. If self-derogatory ideation is present in grief, it typically involves perceived failings vis-a-vis the deceased (eg not visiting frequently enough, not telling the deceased how much he or she was loved). If a bereaved individual thinks about death and dying, such thoughts are generally focused on the deceased and possibly about ‘joining’ the deceased, whereas in a MDE such thoughts are focused on ending one’s own life because of feeling worthless, undeserving of life, or unable to cope with the pain of depression.
- A proposed criteria for persistent complex bereavement disorder was added to conditions for further study.
Why were the changes made?
- Normal adjustment to bereavement can last a number of years and there is little data to support the two month exclusion.
- Bereavement is recognised as a significant stressor that can precipitate a major depressive episode. There is no evidence that bereavement is any different from other significant stressor such as injury, rape or relationship breakdown.
- When major depressive disorder occurs in the context of bereavement, it adds an additional risk for symptoms such as suffering, feelings of worthlessness and suicide.
- Bereavement-related major depression is most likely to occur in individuals with past personal and family histories of major depressive episodes.
What do these changes mean?
The bereavement exclusion now allows clinicians to exercise their professional judgment as to whether an individual with symptoms of major depression and who is grieving are diagnosed with depression. The DSM-5 is intended as a guide only. Decisions about diagnosis and treatment is meant to be based on symptom criteria, as well as the subjective ways individuals are experiencing themselves and the world around them. The detailed footnote has replaced the DSM-IV bereavement exclusion to aid clinicians in making the distinction between the symptoms characteristic of bereavement and those of a major depressive episode.
There has been a reasonable concern that individuals previously considered to be experiencing a variation of normal grief would now get the label of a mental disorder. Improper use of this change could lead to an inaccurate and unnecessary mental disorder diagnosis which could have many harmful effects. However, removing the bereavement exclusion may help prevent major depression from being overlooked and facilitate the possibility of appropriate treatment, including therapy or other interventions, earlier than would otherwise be the case.
If you or someone you know is suffering from grief and/or depression or you would like to know more about the changes to a diagnosis of major depressive disorder in DSM-5, call M1 Psychology on (07) 3067 9129 to book an appointment.
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.
- Bonanno, G. A., & Kaltman, S. (2001). The varieties of grief experience. Clinical Psychology Review, 21, 705–734.
- Carnelley, K. B., Wortman, C. B., Bolger, N., & Burke, C. T (2006). The Time Course of Grief Reactions to Spousal Loss: Evidence From a National Probability Sample. Journal of Personality and Social Psychology, 91(3). Doi: 10.1037/0022-3518.104.22.1686
- Hall, C. (2014). Bereavement and depression in the DSM-5. InPsych: The Bulletin of the Australian Psychological Society, 36(4), 22-23.