Editorial

Depression, Bereavement, and Understandable Intense Sadness: Should the DSM-IV Approach Be Revised?
he issue of the differentiation between depression and understandable intense sadness (representing a normal response to an adverse life event) has significant clinical, scientific, political, and ethical implications, which have become particularly visible in the past few decades, in parallel with the escalation of the prevalence rates of depression in the community, of the estimated social costs of depression, of the number of people on treatment for depression, and of the prescriptions of antidepressant medications (1). Psychiatry has been accused of inappropriately medicalizing the ordinary experiAccording to DSM-IV, ence of sadness in order to expand the range of its jurisdiction (2), and the high prevalence rates periods of sadness are of depression reported by community studies inherent aspects of the have been regarded as unbelievable even by some prominent psychiatrists, who have em- human experience, which phasized the risk to misdiagnose normal reac- should not be diagnosed tions to a difficult environment as a mental disas a major depressive order (3). According to DSM-IV, periods of sadness are episode unless criteria are inherent aspects of the human experience, met for severity, duration, which should not be diagnosed as a major depressive episode unless criteria are met for sever- and clinically significant ity, duration, and clinically significant distress or distress or impairment. impairment. The implication of this statement is that understandable intense sadness following an adverse life event does qualify for the diagnosis of major depression if the severity, duration, and impairment criteria are fulfilled. In other terms, the context in which the depressive symptoms occur is not relevant to the diagnostic decision; what counts is the clinical picture. The only exception to this rule is represented by bereavement. If the symptoms begin within 2 months of the death of a loved one and do not persist beyond these 2 months, the diagnosis of major depression should not be made, unless the symptoms are associated with marked functional impairment or include morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. The rationale for this exclusion criterion can be found in the Introduction to DSM-IV: in order to represent a mental disorder, a condition must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one (p. xxi). A depressive state is an expectable and culturally sanctioned response to the death of a loved one and, as such, does not represent a mental disorder. Some empirical support to this position is provided by the high prevalence of a major depressive syndrome, ranging from 35% to 58%, 1 month after the death of a loved one (4, 5) and by the fact that most bereaved people describe themselves as being what they would have expected to be given the circumstances, whereas depressed patients experience their condition as a change, not usual self (4). The asymmetry introduced by DSM-III/IV between the death of a loved one and other major adverse life events has, not surprisingly, attracted the attention of researchers. In this issue, Kendler et al. (6) report that the similarities between bereavement-related

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and other life stressor-related depression far outweigh their differences, arguing against the continued use of the bereavement exclusion criterion in DSM-V. In another recent paper, Wakefield et al. (7), on the basis of similar findings, proposed to exclude both bereavement-triggered and other loss-triggered uncomplicated intense sadness from the DSM-V diagnosis of major depression (i.e., to introduce a contextual criterion excluding intense sadness that appears proportionate to a loss). These opposite proposals based on the same research evidence are likely to divide our field and the public opinion for several years. Of course, both proposals have significant treatment implications. On the one hand, the risk is to medicalize an adaptive response, thus disrupting the individuals coping processes. On the other, the risk is to deprive a person with a full depressive syndrome of a treatment that may be needed. Furthermore, the impact of the implementation of either proposal on the prevalence rates of major depression is likely to be substantial: for instance, in the community sample studied by Wakefield et al. (7), uncomplicated other loss-triggered cases accounted for 20.1% of all cases of major depression, and uncomplicated bereavement-triggered cases for 6.5%. The issue is even more complex than it may appear to an unsophisticated thinker. The death of a loved one is a clear-cut, easily ascertainable life event that is usually out of the persons control, but other adverse life events may be quite different in these respects. The presence itself of a depressive state may impair the accuracy of a persons report of recent life events or may expose a person to adverse events. The experimental induction of depressed mood has been found to produce an increase in reports of past stressful events (8), and the relationship between depression and dependent events (i.e., events that can be explained by the depressive state, such as being fired from a job) has been found to be stronger than the relationship between depression and independent events (9). Furthermore, whether an adverse life event has been really decisive in triggering a depressive state may be difficult to establish in several cases. This is well known since the 1960s, when Aubrey Lewis, testing a set of criteria aimed to distinguish between contextual and endogenous depression, concluded that most depressive cases were examples of the interaction of organism and environment, so that it was impossible to say which of the factors was decidedly preponderant (10). Further research is clearly needed to explore the applicability and reliability of a contextual criterion in the diagnosis of major depression and the clinical utility of such a criterion for the prediction of treatment response and clinical outcome. The limited available research evidence suggests that definite situational major depression does not differ from definite nonsituational major depression on many clinical and psychosocial variables (11) and that response to antidepressant medications is unrelated to whether or not major depression is preceded by a life event (12). At the present state of knowledge, it may be therefore unwise to disallow the diagnosis of major depression in a person meeting the severity, duration, and impairment criteria for that diagnosis just because the depressive state occurs in the context of a significant life event. On the other hand, the removal of the bereavement exclusion criterion from the DSMV diagnosis of major depressiona move that may be perceived as a further step in psychiatrys attempt to pathologize normal human processesrequires strong and unequivocal research evidence. Some differences between bereavement-related and other life stressor-related depression found by Kendler et al. (6) (the lower percentage of bereaved individuals who sought treatment; the lower levels of neuroticism in those people) and by Wakefield et al. (7) (the lower proportion of bereaved people who reported that their condition interfered with life a lot) seem to point in the DSM-IV direction and deserve further investigation. Moreover, bereavement may be a quite different experience after the death, for instance, of a son or a friend (these events were included in the same category in the study by Kendler et al.) or in the elderly compared to younger peo1374
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ple (the mean age at index episode, in Kendler et al.s sample, was 35 years). Finally, if we expect DSM-V to be more widely used in various cultural contexts than DSM-IV, some cross-cultural validation of Kendler et al.s findings is probably warranted.
References
1. Horwitz AV, Wakefield JC: The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder. Oxford, UK, Oxford University Press, 2007 2. Kutchins H, Kirk SA: Making Us Crazy. DSM: The Psychiatric Bible and the Creation of Mental Disorders. New York, The Free Press, 1997 3. Spitzer RL, Wakefield JC: DSM-IV diagnostic criterion for clinical significance: does it help solve the false positives problem? Am J Psychiatry 1999; 156:18561864 4. Clayton PJ, Herjanic M, Murphy GE, Woodruff R Jr: Mourning and depression: their similarities and differences. Can Psychiatr Assoc J 1974; 19:309312 5. Harlow SD, Goldberg EL, Comstock GW: A longitudinal study of the prevalence of depressive symptomatology in elderly widowed and married women. Arch Gen Psychiatry 1991; 48:10651068 6. Kendler KS, Myers J, Zisook S: Does bereavement-related major depression differ from major depression associated with other stressful life events? Am J Psychiatry 2008; 165: 14491455 7. Wakefield JC, Schmitz MF, First MB, Horwitz AV: Extending the bereavement exclusion for major depression to other losses: evidence from the National Comorbidity Survey. Arch Gen Psychiatry 2007; 64:433440 8. Cohen LH, Towbes LC, Flocco R: Effects of induced mood on self-reported life events and perceived and received social support. J Pers Soc Psychol 1988; 55:669674 9. Williamson DE, Birmaher B, Anderson BP, Al-Shabbout M, Ryan ND: Stressful life events in depressed adolescents: the role of dependent events during the depressive episode. J Acad Child Adolesc Psychiatry 1995; 34: 591598 10. Lewis A: Melancholia: a clinical survey of depressive states, in Inquiries in Psychiatry: Clinical and Social Investigations. Edited by Lewis A. New York, Science House, 1967, pp 3072 11. Hirschfeld RMA, Klerman GL, Andreasen NC, Clayton PJ, Keller MB: Situational major depressive disorder. Arch Gen Psychiatry 1985; 42:11091114 12. Anderson IM, Nutt DJ, Deakin JFW, on behalf of the Consensus Meeting and endorsed by the British Association for Psychopharmacology: Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 1993 British Assocociation for Psychopharmacology guidelines. J Psychopharmacol 2000; 14:320

MARIO MAJ, M.D., Ph.D.

Received July 17, 2008; accepted July 22, 2008. From the Department of Psychiatry, University of Naples SUN, Naples, Italy. Address correspondence and reprint requests to Prof. Maj, Department of Psychiatry, University of Naples SUN, Largo Madonna delle Grazie, 80138 Naples, Italy; majmario@tin.it (e-mail). Editorial accepted for publication July 2008 (doi: 10.1176/appi.ajp.2008.08071047). Prof. Maj reports no competing interests.

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