Grief, Depression, and the DSM-5

Richard A. Friedman, M.D.

N Engl J Med 2012; 366:1855-1857May 17, 2012DOI: 10.1056/NEJMp1201794

From the Department of Psychiatry, Weill Medical College of Cornell University, New York.

Nearly 2.5 million Americans die each year, leaving behind an even larger group of grief-stricken
people.1 Such a universal human experience as grief is recognized by the lay public and medical
professionals alike as an entirely normal and expected emotional response to loss. Clinicians and
researchers have long known that, for the vast majority of people, grief typically runs its course within 2
to 6 months and requires no treatment.
In a common clinical scenario, a patient who has just lost a loved one presents to a physician with mild
depressive symptoms, such as sadness, tearfulness, and insomnia. Under the guidelines of the
American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th edition
(DSM-IV), a practitioner would reasonably view these depressive symptoms as grief-related and not
diagnose clinical depression: the depressive symptoms are mild and have lasted less than 2 months. A
clinician can make a diagnosis of major depression even in the context of grief if the depressive
symptoms are unrelenting or if the patient has severe impairment of functioning or delusional or
suicidal thinking. (To receive a diagnosis of major depression according to the DSM-IV, a patient must
have either depressed mood or loss of pleasure plus four or more associated symptoms such as
appetite loss, insomnia or hypersomnia, psychomotor change, fatigue, low self-esteem, diminished
concentration, and recurrent thoughts of death or suicide for at least a 2-week period.)
Admittedly, it can be challenging for many practitioners to tell the difference between acute grief and
depression. Grief-stricken patients frequently report symptoms that are also typical of major
depression, such as sadness, tearfulness, insomnia, and decreased appetite. But, as numerous
researchers have noted, grief rarely produces the cognitive symptoms of depression, such as low selfesteem or feelings of worthlessness. And although bereaved patients may fantasize about being
reunited with a lost loved one through death, they do not generally experience the explicit and
persistent suicidal ideation typical of major depression.
Thus, the DSM-IV clearly distinguishes the normal and expected grief after loss from the more
persistent and severe symptoms of clinical depression. And it does so for good reason: although
uncomplicated grief can be painful, it is short-lived and benign, and it does not severely impair function
or increase the risk of suicide as major depression does.

Now, however, the American Psychiatric Association is considering making a significant change to the
definition of depression in the upcoming 5th edition of the DSM, which would specifically characterize
bereavement as a depressive disorder.2 In removing the so-called bereavement exclusion, the DSM-5
would encourage clinicians to diagnose major depression in persons with normal bereavement after
only 2 weeks of mild depressive symptoms. Unfortunately, the effect of this proposed change would be
to medicalize normal grief and erroneously label healthy people with a psychiatric diagnosis. And it will
no doubt be a boon to the pharmaceutical industry, because it will encourage unnecessary treatment
with antidepressants and antipsychotics, both of which are increasingly used to treat depression and
anxiety.
Nor will this change help practitioners deal with the common dilemma presented by the bereaved
patient with mild depressive symptoms the question of how to tell whether such a patient is heading
toward major depression or should be left alone to grieve. The answer is often not clear after a first
visit, in which case a period of watchful waiting is reasonable. If the symptoms persist or intensify, a
diagnosis of clinical depression becomes more likely.
This problem, I believe, is at the heart of the controversy about redefining the diagnostic criteria for
depression in the upcoming DSM-5. The experts who favor the change are concerned that some
bereaved patients who need psychiatric treatment will go without it because their depressive
symptoms will be reflexively attributed to their grief under the bereavement exclusion.
The concern is understandable, particularly in light of the fact that only 50% of people with major
depression in the general population and 33% of patients with major depression in the primary care
setting receive any treatment for depression.3 But the argument that there is no essential difference
between grief-related depression and clear-cut major depression is contradicted by rigorous data. For
example, a study using data from the National Epidemiologic Survey on Alcohol and Related
Conditions showed that persons who had a bereavement-related depressive syndrome at baseline
were no more likely over a 3-year follow-up period to have a major depressive episode than those who
had no lifetime history of major depression at baseline. In contrast, subjects who had had an episode
of major depression at baseline were significantly more likely to have a recurrence of depression
during the 3-year follow-up than those without a history of depression or those who had only had
bereavement-related depression.4
Thus, it seems clear that depressive symptoms in the context of grief are fundamentally different, in
terms of course and prognosis, from those of clinical depression. But that does not mean that all grief
goes smoothly or should be ignored by clinicians.
For example, bereaved persons with a history of major depression are obviously at high risk for
depressive recurrence in the context of loss, as they would be in the face of numerous stressors, and

they should be monitored closely for worsening neurovegetative symptoms or the emergence of
suicidal or delusional thinking. We also know that 10 to 20% of bereaved people do not get over their
grief easily and go on to develop a syndrome of complicated grief, characterized by an intense and
persistent longing for the deceased, a sense of anger and disbelief over the death, and a disturbing
preoccupation with the lost one.5
But for most people, grief resolves naturally on its own. Because the vast majority of bereaved and
clinically depressed patients are seen by primary care practitioners, it is critical that such practitioners
be skilled at distinguishing between clinical depression, which requires treatment, and uncomplicated
grief, which is an entirely normal emotional response to loss. The medical profession should normalize,
not medicalize, grief.
Editor's note: On May 9, 2012, the APA announced that although the bereavement exclusion will still
be eliminated from the definition of major depression, a footnote will be added indicating that sadness
with some mild depressive symptoms in the face of loss should not necessarily be viewed as major
depression.