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When Bereavement is No Longer Normal

Bereavement and major depression overlap in that both involve sleep disturbance, appetite disturbance and withdrawal from usual activities in association with intense sadness. However, there are some important differences. Bereavement is in direct response to significant loss and the emotional reactions tend to come in waves, intermittently accompanied by fond memories of the past. There are no true thoughts of suicide, but rather of wanting to be with the deceased. Major depression may fluctuate in intensity over the day (being characteristically worst in the morning) but low mood, impaired function and negative thoughts persist despite this. Low self-esteem and self-loathing are characteristics of major depression rather than bereavement. A reactive depression is likely in some individuals after bereavement, but tends not to be pervasive or severe.

DSM IV stated that a major depression could not be diagnosed within two months of bereavement (“bereavement exclusion”), as this would be interchanging a normal reaction for a psychiatric diagnosis (major depression). As a result of the differences between depression and bereavement as noted above, DSM V has been changed from DSM IV because it was considered unreasonable to suggest that, for example, one stressor such as physical trauma could precipitate a major depression, but bereavement could not. There were avenues to diagnose severe major depression during bereavement under DSM V1 criteria, but these focussed on symptoms and signs such as suicidality, depressive psychosis, psychomotor retardation, delusions of worthlessness or extremely poor daily function.

It is now recognised that major depression can develop in response to bereavement. It may be present prior to the passing of a loved one, especially after a long illness, or it may be triggered or worsened in vulnerable individuals due to mourning. It may occur due to relationship breakdowns in response to bereavement or from underlying medical illness. There is no difference in response to treatment, illness course or outcome when a patient has major depression in association with bereavement compared to major depression in other situations.

 

1. American Psychiatric Association, Major Depressive Disorder and the “Bereavement Exclusion” 2013
http://www.dsm5.org/Documents/Bereavement%20Exclusion%20Fact%20Sheet.pdf

2. Ronald Pies. The Bereavement Exclusion and DSM-5: An Update and Commentary. Innov Clin Neurosci. 2014 Jul-Aug; 11(7-8): 19–22.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4204469/