Grief after loss of a significant other may become a disease

Feb 16 2011

In the current issue of Psychotherapy and Psychosomatics, a group of French investigators headed by Guy Chouinard presents data that indicate that grief after the loss of a significant other may become a disease. One issue facing the DSM-V in the revision of the criteria for major depressive disorder (MDD) concerns bereavement criterion E, which often leads to exclusion from major depressive episode (MDE). The rationale behind criterion E was that symptoms of bereavement-related sadness resemble those of major depression without the presence of MDD. Bereavement is the only stressful life event (SLE) which is an exclusion criterion for a DSM axis I diagnosis, unless depressive symptoms associated with bereavement last longer than 2 months or meet the bereavement descriptive E criterion for major depression. Several authors have questioned the validity of excluding bereavement from major depression when all other inclusion criteria are met. SLE, including bereavement, have been found to contribute to, initiate and maintain MDD. More recently, the Authors of this paper reported that DSM-IV bereavement-excluded subjects were more severely depressed than MDE subjects without bereavement, and at least as severely depressed as MDE subjects with bereavement. At this time, the DSM-V is proposing to delete bereavement exclusion criterion E for major depression (www.DSM5.org). In the present article, the investigators propose to revise DSM-IV bereavement exclusion and keep the V code for bereavement as suggested by Paula Clayton. In addition, in the event that criterion E is deleted, they believe that criterion A for major depression should be revised to require at least 7 of the 9 criterion A inclusion symptoms for MDE in all types of MDD, which would satisfy the concerns raised by Lichtenberg, Belmaker and Bech about the overinclusiveness of criterion A, leading to overdiagnosis of MDE. Adjusting the number of inclusion symptoms of criterion A reinforces the dimensional approach to depression initiated by the DSM-III (1980) and DSM-III-R (1987). To avoid a 'single catchall entity' diagnosis of MDE , depression subtypes can be used, including bereavement depression. Bereavement depression could be classified as a stress event subtype of MDD when bereaved subjects meet the new proposed inclusion criterion A. Lichtenberg and Belmaker proposed 10 subtypes of depression, and Bech kept 3 subtypes of stress event depression, but did not include bereavement depression. The Authors of this paper propose the following 6 stress event MDD subtypes: (1) bereavement depression; (2) childhood trauma depression; (3) separation depression; (4) postpartum depression; (5) late-life depression, and (6) seasonal depression. Now is the time to reevaluate depression subtypes and MDD, and allow subtypes for some of the welldefined stress event depressions.