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Bereavement and the Diagnosis of Major Depressive Episode in the National Epidemiologic Survey on Alcohol and Related Conditions

J Clin Psychiatry 2012;73(2):208-215
10.4088/JCP.10m06080

Objective: Bereavement-related depression is excluded from a diagnosis of major depressive episode (MDE) in DSM-IV, unless the syndrome is prolonged or complicated. The objective of this study is to assess the validity of the bereavement exclusion by comparing characteristics of bereavement-related episodes that are excluded from a diagnosis and bereavement-related episodes that qualify for a diagnosis (complicated bereavement) to MDE.

Method: We used data from 2 waves of the National Epidemiologic Survey on Alcohol and Related Conditions (n = 43,093) to compare bereavement-excluded depression and complicated bereavement to MDE with respect to indicators of preexisting risk for psychopathology (antecedent indicators) and indicators of disorder severity measured at baseline and at the study’s 3-year follow-up interview (consequent indicators). The primary outcome measure was the Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV.

Results: Compared to individuals with MDE, individuals with bereavement-excluded depression had lower risks of preexisting psychiatric disorders (eg, 0.44 lower odds of social phobia, P = .006), fewer depressive episodes (recurrence rate 0.37 times lower, P < .001), less psychosocial impairment (P < .001), a 0.18 times lower odds of seeking treatment (P < .001), and a lower risk of psychiatric disorders during a 3-year follow-up period. Unexpectedly, this same pattern of differences was observed between individuals with complicated bereavement and MDE.

Conclusions: Despite the presence of a clinically significant depressive episode, bereavement-excluded depression is in many ways less indicative of psychopathology than MDE. However, complicated bereavement was more similar to bereavement-excluded depression than to MDE. We therefore question whether the DSM-IV criteria validly distinguish between nondisordered loss reactions (bereavement-excluded depression), pathological loss reactions (complicated bereavement), and nonloss-related MDE.

J Clin Psychiatry

Submitted: February 25, 2010; accepted October 25, 2010.

Online ahead of print: August 23, 2011 (doi:10.4088/JCP.10m06080).

Corresponding author: Stephen E. Gilman, ScD, Department of Society, Human Development, and Health, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115 (sgilman@hsph.harvard.edu).