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Letter to the Editor

Reply to Back to "Normal Bereavement"

Sidney Zisook, MD; Charles F. Reynolds III, MD; Ronald Pies, MD; Naomi M. Simon, MD; Barry Lebowitz, PhD; and M. Katherine Shear, MD

Published: February 15, 2011

See the original letter

Dr Zisook and Colleagues Reply

To the Editor: We thank Dr Clayton for her thoughtful comments and careful reading of our article describing why we believe the bereavement exclusion has outlived its usefulness.1 Dr Clayton’s seminal work in this area is both historically and conceptually noteworthy. It is with the utmost respect and admiration that we disagree with her position on this matter. First, to highlight and clarify an important myth regarding eliminating the bereavement exclusion: those who favor the change do not want to imply that grief should be over within 2 weeks, 2 months, or even longer after the death of a loved one. Elsewhere, we have pointed out that grief and major depression are separate constructs, although there is some symptomatic overlap, and that many bereaved individuals grieve intensely for protracted periods, if not for a lifetime, whether or not they also meet criteria for a major depressive episode (MDE). Further, grief does not become pathologic or transform into major depression at 2 months. Rather, "normal" grief may last, in its various forms, for months to years.2,3 However, we do think it important to point out that, for vulnerable individuals, the death of a loved one may precipitate an episode of major depression. When that happens, the grief may be even more severe and protracted than otherwise.

We also would like advocates of retaining the bereavement exclusion to consider 4 hypothetical cases: Mr A, Mr B, Mr C, and Mr D. In each instance, the individual meets full symptomatic criteria for an MDE, has no suicidal ideation or morbid feelings of worthlessness, and has moderate levels of dysfunction. The cases are identical in all ways, with the exceptions that in Mr A’s case, it is 4 weeks after the death of his dearly departed wife; Mr B’s wife is fine, but he has been diagnosed with terminal lung cancer; Mr C and his wife are both healthy and retired, but have just lost their life’s savings and home to terrible investments; and Mr D and his wife are healthy, wealthy, and wise.

According to the DSM-IV-TR (but not, we might add, the ICD-10), only Mr B, Mr C, and Mr D have an MDE; in contrast, Mr A has "bereavement." But this distinction makes sense only if Mr A’s depressive syndrome is fundamentally different, with a better prognosis or unique treatment requirements compared to Mr B’s , Mr C’s , or Mr D’s MDE. However, we are unaware of any published data supporting the argument that depressive syndromes occurring after the death of a loved one are in any meaningful way different than other, non-bereavement-related depressions. Instead, several recent studies4-7 have found bereavement-related major depressions to be essentially identical to other, non-bereavement-related depressions, and 2 recent literature reviews8,9 have found that the preponderance of available data provide little support for the bereavement exclusion. Bereavement-related depressions are similar to other, non-bereavement-related depressions in risk factors, intensity, course, comorbidity, biologic features, and treatment response.

In one of her seminal studies on grief and depression,10 Clayton concluded that "grief is grief and grief is not a good model for psychotic depression." We agree. In fact, we do not think it is a model for any MDE. Rather, grief is a model for stress and, like other severe stressors, may precipitate or worsen a variety of other conditions, including, perhaps most prominently, an MDE. And just like other, non-bereavement-related MDEs, bereavement-related MDEs are often recurrent, genetically influenced, impairing, and treatment responsive.5 Thus, we do not feel that we are doing the person a service by calling their depression by another name (ie, bereavement).

Instead, we believe that the most humane and data-based response is to be watchful for the emergence of depressive symptoms in recently bereaved individuals, especially those with other risk factors, and to make the diagnosis of MDE when the full symptomatic, duration, and severity features are present. We do not advocate actively treating every episode of major depression as we recognize that spontaneous remissions are the rule rather than the exception, especially for relatively mild MDEs.11 Rather, we recommend that clinicians consider treatment decisions (whether, how, and when to treat) on the basis of past history, severity, suicide risk, persistence and pervasiveness of symptoms, comorbidity, and patient preferences.12

We strongly feel that it is no longer justifiable to deny appropriate diagnosis and access to meaningful treatment on the basis of a bereavement exclusion that has not been empirically validated in the 30-plus years of its existence. We welcome further dialogue on this important issue and continued data-based refinement of definitions and boundaries for major psychiatric disorders. While we are at one with Dr Clayton in affirming the validity of grief, we will not grieve the loss of the bereavement exclusion from the DSM-5.


1. Zisook S, Reynolds CF 3rd, Pies R, et al. Bereavement, complicated grief, and DSM, part 1: depression. J Clin Psychiatry. 2010;71(7):955-956. PubMed doi:10.4088/JCP.10ac06303blu

2. Zisook S, Simon NM, Reynolds CF 3rd, et al. Bereavement, complicated grief, and DSM, part 2: complicated grief. J Clin Psychiatry. 2010;71(8):1097-1098. PubMed doi:10.4088/JCP.10ac06391blu

3. Zisook S, Shear K. Grief and bereavement: what psychiatrists need to know. World Psychiatry. 2009;8(2):67-74. PubMed

4. Wakefield JC, Schmitz MF, First MB, et al. Extending the bereavement exclusion for major depression to other losses: evidence from the National Comorbidity Survey. Arch Gen Psychiatry. 2007;64(4):433-440. PubMed doi:10.1001/archpsyc.64.4.433

5. 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(11):1449-1455. PubMed doi:10.1176/appi.ajp.2008.07111757

6. Kessing LV, Bukh JD, Bock C, et al. Does bereavement-related first episode depression differ from other kinds of first depressions? Soc Psychiatry Psychiatr Epidemiol. 2010;45(8):801-808. PubMed doi:10.1007/s00127-009-0121-6

7. Karam EG, Tabet CC, Alam D, et al. Bereavement related and non-bereavement related depressions: a comparative field study. J Affect Disord. 2009;112(1-3):102-110. PubMed doi:10.1016/j.jad.2008.03.016

8. Zisook S, Kendler KS. Is bereavement-related depression different than non-bereavement-related depression? Psychol Med. 2007;37(6):779-794. PubMed doi:10.1017/S0033291707009865

9. Zisook S, Shear K, Kendler KS. Validity of the bereavement exclusion criterion for the diagnosis of major depressive episode. World Psychiatry. 2007;6(2):102-107. PubMed

10. Bornstein PE, Clayton PJ, Halikas JA, et al. The depression of widowhood after thirteen months. Br J Psychiatry. 1973;122(570):561-566. PubMed doi:10.1192/bjp.122.5.561

11. Posternak MA, Solomon DA, Leon AC, et al. The naturalistic course of unipolar major depression in the absence of somatic therapy. J Nerv Ment Dis. 2006;194(5):324-329. PubMed doi:10.1097/01.nmd.0000217820.33841.53

12. Lamb K, Pies R, Zisook S. The bereavement exclusion for the diagnosis of major depression: to be, or not to be. Psychiatry (Edgmont). 2010;7(7):19-25. PubMed

Sidney Zisook, MD

Charles F. Reynolds III, MD

Ronald Pies, MD

Naomi M. Simon, MD

Barry Lebowitz, PhD

M. Katherine Shear, MD

Author affiliations: Department of Psychiatry, University of California San Diego and San Diego VA Healthcare System (Dr Zisook); Department of Psychiatry, University of Pittsburgh School of Medicine, and Department of Community and Behavioral Health Science, University of Pittsburgh Graduate School of Public Health, Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania (Dr Reynolds); Department of Psychiatry, Tufts University School of Medicine, Boston, and Department of Psychiatry, State University of New York (SUNY) Upstate Medical University, Syracuse (Dr Pies); Department of Psychiatry, Harvard Medical School and Massachusetts General Hospital, Boston (Dr Simon); Department of Psychiatry, University of California San Diego (Dr Lebowitz); and Columbia University School of Social Work and Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York (Dr Shear). Potential conflicts of interest: Dr Zisook has received grant/research support from Pamlab. In the last 12 months, Dr Simon has received grant/research support from Forest and has been a speaker (CME) for Pfizer. Drs Reynolds, Pies, Lebowitz, and Shear report no financial or other relationships relevant to the subject of this letter. Funding/support: The article discussed in this letter was supported by National Institute of Mental Health grant R01 MH085297 and grants from the American Foundation for Suicide Prevention and the John A. Majda, MD, Memorial Foundation.

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