Distinguishing Bereavement from Depression in DSM-5: Evidence from Longitudinal Epidemiologic Surveys.

The DSM-IV definition of mental disorder states that a disorder is not “merely an expectable and culturally sanctioned response to a particular event” and that it represents a “dysfunction in the individual” (1). Because adverse experiences are a part of life and negative emotions arise as natural and adaptive responses to these experiences, much of the psychological distress that humans experience is considered expectable, culturally sanctioned, and functional. Thus, sadness is not a mental disorder in the DSM. However, adverse experiences can trigger negative emotional reactions that are so extreme that they are considered pathological. A large body of research has demonstrated the link between stressful life events and major depression (2-4), which is the main operationalization of pathological sadness in the DSM. If the symptoms that the individuals experience meet the manual's criteria for a major depressive episode (MDE), the context in which the symptoms present does not influence diagnosis, with one exception: bereavement. DSM-IV acknowledges that individuals experiencing bereavement may present with symptoms resembling a MDE. For that reason, the threshold between normal distress and disorder is somewhat elevated for the bereaved. For the diagnosis of MDE to be applied in these individuals, symptoms need to persist longer than two months after the loss (as opposed to two weeks for the non-bereaved), or the individual has to experience marked functional impairment, psychotic symptoms, psychomotor retardation, suicidal ideations or morbid preoccupations with worthlessness. Bereavement-related depressive episodes lasting 2 months or longer or presenting any of these characteristics are sometimes referred to as cases of “complicated bereavement” (5). It should be noted that this term refers to depressive episodes that occur in the context of bereavement but are still considered MDEs. It should not be confused with “complicated grief”, which is a distinct syndrome characterized by prolonged, debilitating, painful emotions such as intense yearning, bitterness, shock, loneliness, and emptiness (6, 7). In recent years, the bereavement exclusion has come under criticism, and some experts have advocated for its removal (8-10). These experts question the validity of bereavement exclusion, maintaining that criteria for MDE should be applied without regard to context. In line with this view, the DSM-5 committee proposed removing the bereavement exclusion from the DSM-5—a proposal that has led to other criticism (11-14). A number of articles published in recent years, including literature reviews and original analyses, have addressed the issue by seeking empirical evidence for the validity of the bereavement exclusion (6, 14-25). These studies pose the question whether individuals who would otherwise meet criteria for major depression, but for whom this diagnosis is precluded because of the bereavement exclusion, have the same disorder as those who are not excluded. The studies generally test the construct validity of the exclusion by comparing individuals with excluded bereavement (EB) to those with major depression on indicators such as risk factors, symptom profiles, and recurrence. Some of the recent reviews and empirical studies have concluded that the available evidence supports removal of the bereavement exclusion from the DSM-5 (6, 15, 16, 20). However, there are problems with the data on which these conclusions are based. In their critical review of past studies of the validity of the bereavement exclusion, Wakefield and First (14) conclude that the past studies largely failed to provide a conclusive answer due to methodological limitations. They noted that in many studies purportedly supporting the removal of the bereavement exclusion, the bereaved group was comprised of both “complicated” and “uncomplicated” bereavement cases, greatly limiting their ability to test the validity of the exclusion as it exists in the DSM. Other studies have used clinical samples, lacked adequate power, inappropriately applied the exclusion criteria, and/or addressed the related but separate question of how bereavement compares to other losses (14). However, three recently published studies (two of which are discussed by Wakefield and First) are less affected by these limitations of past literature (18, 19, 23). These studies used data from large scale longitudinal epidemiologic surveys and directly compared EB cases with cases of major depression. The purpose of this paper is to provide a summary of the evidence for the validity of the bereavement exclusion based on these studies.