Extending the Bereavement Exclusion for Major Depression to Other Losses

Abstract

Context: Symptoms of intense bereavement-related sadness may resemble those of major depressive disorder (MDD) but may not indicate a mental disorder. To avert false-positive diagnoses, DSM criteria for MDD exclude uncomplicated bereavement of brief duration and modest severity. However, the DSM does not similarly exempt depressive reactions to other losses, even when they are uncomplicated in duration and severity.Objective: To test the validity of the DSM exclusion of uncomplicated depressive symptoms only in response to bereavement but not in response to other losses.Design: Community-based epidemiological study.Participants: From the National Comorbidity Survey (NCS) of 8098 persons aged 15 to 54 years representative of the US population, we identified individuals who met MDD symptom criteria and whose MDD episodes were triggered by either bereavement (n=157) or other loss (n=710). Intervention:We divided the bereavement and other loss trigger groups into uncomplicated and complicated cases by applying the NCS algorithm for uncomplicated bereavement to the reactions to other losses. We then compared uncomplicated bereavement and uncomplicated reactions to other losses on a variety of disorder indicators and symptoms.Main Outcome Measures: Nine disorder indicators, as follows: number of symptoms, melancholic depression, suicide attempt, duration of symptoms, interference with life, recurrence, and 3 service use variables.Results: Episodes of uncomplicated depression triggered by bereavement and by other loss have similar symptom profiles and are not significantly different for 8 of 9 disorder indicators. Moreover, uncomplicated reactions, whether triggered by bereavement or other loss, are significantly lower than complicated reactions on almost all disorder indicators. Conclusion:The NCS data do not support the validity of uniquely excluding uncomplicated bereavement but not uncomplicated reactions to other losses from MDD diagnosis.

The Evolving Understanding of Major Depression Epidemiology: Implications for Practice and Policy

“…However, the somewhat arbitrary lack of a comparable exclusion criterion for other types of losses and threats indicates that individuals with reactions that may be comparable with bereavement meet DSM-IV criteria for MD. 10 A third consideration is the issue of recall bias. Many episodes of MD appear to be forgotten later in life, 11 which means that most or all epidemiologic estimates of MD lifetime prevalence are probably underestimates.…”

Dr Corruble and Colleagues Reply

“…Unfortunately, our data cannot answer these questions. Nonetheless, on the basis of the absence of published data about what could be a relevant, coherent, and evidence-based rewording, the suggestions of Clayton, 4 and previous reports (especially from Dr Wakefield) arguing that bereavement and other life stressors should not have different status, 5 we would argue for deleting the BE, while possibly retaining a V code for bereavement. Although there are some concerns that this could lead to an unacceptably high rate of major depressive disorder (MDD) being diagnosed, there are other ways of addressing this concern, such as insisting on a higher criterion A symptom cutoff score 6 or a longer duration of symptoms.…”

Sobrediagnóstico de trastornos mentales y criterios diagnósticos del DSM: la perspectiva de Jerome Wakefieldx

“…Entre estas implicaciones señala las siguientes: 1) Un "auténtico trastorno" no tiene probablemente las mismas implicaciones en términos de gravedad y cronicidad que un malestar o impedimento que no es derivado de una disfunción individual sino de condiciones contextuales. Si bien puede tener una apariencia análoga al patrón sintomático de diversos trastornos mentales, la ausencia de una disfunción propiamente tal probablemente implicará mayores posibilidades de recuperación de parte de la persona 17 . 2) Si bien personas con o sin trastorno mental pueden requerir y beneficiarse del apoyo que le pueden brindar profesionales de la salud mental, la conceptualización de un problema como algo que no lo es, puede hacer menos pertinente el tipo de ayuda ofrecida.…”

“…A diferencia de la distinción clásica y superada entre depresión reactiva y endógena, este planteamiento no supone que la existencia de un evento desencadenante corresponda a una depresión reactiva, sino que la presencia de sintomatología depresiva "no complicada", al igual que el duelo "no complicado", puede satisfacer los criterios sintomáticos de un trastorno depresivo sin que se justifique ese diagnóstico, y también reconoce que pueden existir eventos vitales asociados al desarrollo de trastornos depresivos propiamente tales. Sus investigaciones han corroborado que diversas pérdidas y adversidades, no solo el duelo, pueden dar lugar a aparentes trastornos depresivos que tienen, sin embargo, implicaciones diferentes a éstos, con una evolución más favorable, y que no se justificaría considerarlos trastornos 17,[21][22][23][24][25][26][27][28][29] . Sus críticas en este aspecto a los criterios diagnósticos de trastornos depresivos se acentuaron luego que el DSM-5 optara por una decisión enteramente opuesta a estos análisis y se decidiera eliminar el duelo como criterio explícito de exclusión del diagnóstico de depresión 30 .…”