Introduction
Ordinary grief is not an illness. Indeed, grieving probably has adaptive value and does not require professional treatment. But grieving persons are not immune to major depressive disorder (MDD), and, indeed, bereavement is a common trigger for MDD. There are, nevertheless, substantial differences between grief and MDD, and experienced clinicians will be able to tell the difference. The elimination of the bereavement exclusion from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, (DSM-5) will not change that. Let's consider the following scenario:
• Mr. Smith is a 72-year-old retired businessman whose wife died of cancer 3 weeks ago. He visits his family doctor and says, "I feel down in the dumps and weepy every day, Doc -- really lousy! I don't get any pleasure out of anything anymore, even stuff I used to love, like watching football. I wake up at 4 in the morning almost every day and have zero energy. I can't keep my mind on anything. I barely eat, and I've lost 10 pounds since Mary passed away. I hate being around other people. Sometimes I feel like I didn't really do enough for Mary when she was sick. God, how I miss her! I can still cook for myself, pay the bills, and so on, Doc, but I'm just going through the motions. I don't enjoy life at all anymore."
Though it's still early after his wife's death -- and some clinicians may want to defer a final diagnosis for another week -- all clinicians should be very concerned about Mr. Smith. He easily meets DSM-IV (and now, DSM-5) symptom and duration criteria for MDD. (A previous bout of MDD in his history would strengthen the likelihood, as would several other clinical findings I have omitted.) And yet, under the present DSM-IV "rules," Mr. Smith probably would not be diagnosed with a major depressive illness. He would simply be called "bereaved." Why? Because he is still within the 2-month period that allows for use of the bereavement exclusion and because Mr. Smith doesn't have the DSM-IV features that allow the clinician to "override" use of the bereavement exclusion -- namely, severe functional impairment, suicidal ideation, psychosis, morbid preoccupation with worthlessness, or extreme guilt. It's important to note that the DSM-IV exclusion rules did not apply to any other type of loss, such as losing one's job or becoming homeless. It is interesting to note that if Mr. Smith's wife had left him for another man, he would meet MDD criteria using current DSM-IV rules!
Many of us who have specialized in the treatment of mood disorders found the DSM-IV criteria not only illogical but also inimical to good clinical care. We were concerned that many bereaved patients like Mr. Smith -- who meet all symptom and duration criteria for MDD but who happen to have lost a loved one within the past 2 months -- would be shunted out of the mental health care system. In the view of many (though not all) mood disorder specialists, the risk of overlooking MDD, with its high potential for suicide, far outweighs the less serious risk of "over-calling" MDD -- the so-called "false positive" scenario.