PERSPECTIVE
be identified in treatment. Only Psychiatrists would start mov-
Some Examples of DSM Diagnoses
Clustered by Causal “Perspectives.”
Brain diseases
Delirium
Schizophrenia
Panic disorder
Personality dimensions
Mental retardation
Obsessive–compulsive personality
Borderline personality
Motivated behaviors
Anorexia nervosa
Conversion disorder
Alcohol dependence
Life encounters
Bereavement
Adjustment disorder
Post-traumatic stress disorder
patient’s clinical picture. This
latter fact led us, in describing
the causal families and their dis-
tinctive ways of affecting mental
life, to name them “perspectives”
and by that metaphor to empha-
size how understanding a case
from one causal viewpoint might
blind the diagnostician to contri-
butions from others.5 PTSD, for
example, is a state of mind pro-
voked by traumatic life encoun-
ters. But for most patients, issues
of behavior and temperament con-
tribute to precipitating and sus-
taining the condition and must
Grief, Depression, and the DSM-5
Richard A. Friedman, M.D.
N early 2.5 million Americans
die each year, leaving behind
an even larger group of grief-
stricken people.1 Such a univer-
sal human experience as grief
is recognized by the lay public
and medical professionals alike
as an entirely normal and expect-
ed emotional response to loss. Cli-
n engl j med 366;20
The New England Journal of Medicine
Downloaded from nejm.org at UC SHARED JOURNAL COLLECTION on March 31, 2015. For personal use only. No other uses without permission.
Copyright © 2012 Massachusetts Medical Society. All rights reserved.
Mental Illness — Comprehensive Evaluation or Checklist?
the painstaking assessment of
patients, which was standard be-
fore the publication of the DSM-
III, can bring the relevant causal
factors to light. Symptom check-
lists will never suffice — and, of
course, were never intended to.
What to recommend now? No
replacement of the criterion-driven
diagnoses of the DSM would be
acceptable; clinicians are too ac-
customed to them, and investiga-
tors cannot forgo the usefulness
of the DSM’s inclusionary and
exclusionary diagnostic criteria
when defining a condition or a
group to be studied. In the new
edition, however, entities could
easily be rearranged so that those
tied causally to diseases, person-
ality dimensions, behaviors, or en-
counters were identified as such
and clustered separately (see table).
Grouping disorders by putative
causation would promote fruitful
thought and, consequently, prog-
ress. Clinicians who were aware
of the causal proposals and their
several practical, heuristic impli-
cations would be encouraged to
proceed more analytically in their
assessments, treatments, and in-
vestigations of patients, while
still using the DSM diagnoses for
their records.
nicians 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,
nejm.org may 17, 2012
ing toward the day when they ad-
dress psychiatric disorders in the
same way that internists address
physical disorders, explaining the
clinical manifestations as prod-
ucts of nature to be comprehend-
ed not simply by their outward
show but by the causal processes
and generative mechanisms known
to provoke them. Only then will
psychiatry come of age as a med-
ical discipline and a field guide
cease to be its master work.
Disclosure forms provided by the authors
are available with the full text of this article
at NEJM.org.
From the Department of Psychiatry and Be-
havioral Sciences, Johns Hopkins University
School of Medicine, Baltimore.
1. Parker G. Beyond major depression. Psy-
chol Med 2005;35:467-74.
2. Fournier JC, DeRubeis RJ, Hollon SD, et al.
Antidepressant drug effects and depression
severity: a patient-level meta-analysis. JAMA
2010;303:47-53.
3. Anthony JC, Folstein M, Romanoski AJ,
et al. Comparison of the lay Diagnostic In-
terview Schedule and a standardized psy-
chiatric diagnosis: experience in eastern
Baltimore. Arch Gen Psychiatry 1985;42:667-
75.
4. Kupfer DJ, Kuhl EA, Narrow WE, Regier
DA. On the road to DSM-V. In: Gordon D, ed.
Cerebrum 2010: emerging ideas in brain sci-
ence. New York: Dana Press, 2010:81-93.
5. McHugh PR, Slavney PR. The perspec-
tives of psychiatry. 2nd ed. Baltimore: Johns
Hopkins University Press, 1998.
Copyright © 2012 Massachusetts Medical Society.
such as sadness, tearfulness, and
insomnia. Under the guidelines
of the American Psychiatric Asso-
ciation’s Diagnostic and Statistical
Manual of Mental Disorders, 4th
edition (DSM-IV), a practitioner
would reasonably view these de-
pressive symptoms as grief-related
and not diagnose clinical depres-
1855
PERSPE C T I V E
sion: 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 unre-
lenting or if the patient has se-
vere 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 de-
pressed 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 concen-
tration, and recurrent thoughts
of death or suicide — for at least
a 2-week period.)
Admittedly, it can be challeng-
ing for many practitioners to tell
the difference between acute
grief and depression. Grief-stricken
patients frequently report symp-
toms that are also typical of ma-
jor depression, such as sadness,
tearfulness, insomnia, and de-
creased appetite. But, as numer-
ous researchers have noted, grief
rarely produces the cognitive symp-
toms of depression, such as low
self-esteem or feelings of worth-
lessness. And although bereaved
patients may fantasize about be-
ing reunited with a lost loved one
through death, they do not gen-
erally experience the explicit and
persistent suicidal ideation typical
of major depression.
Thus, the DSM-IV clearly dis-
tinguishes the normal and expect-
ed grief after loss from the more
persistent and severe symptoms of
clinical depression. And it does
so for good reason: although un-
complicated grief can be painful,
it is short-lived and benign, and
it does not severely impair func-
1856
Downloaded from nejm.org at UC SHARED JOURNAL COLLECTION on March 31, 2015. For personal use only. No other uses without permission.
Copyright © 2012 Massachusetts Medical Society. All rights reserved.
tion or increase the risk of suicide
as major depression does.
Now, however, the American
Psychiatric Association is consid-
ering making a significant change
to the definition of depression in
the upcoming 5th edition of the
DSM, which would specifically
characterize bereavement as a de-
pressive disorder.2 In removing
the so-called bereavement exclu-
sion, the DSM-5 would encour-
age 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 erro-
neously 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 de-
pression and anxiety.
Nor will this change help prac-
titioners deal with the common
dilemma presented by the be-
reaved patient with mild depres-
sive symptoms — the question of
how to tell whether such a pa-
tient is heading toward major de-
pression 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 psy-
n engl j med 366;20 nejm.org may 17, 2012
The New England Journal of Medicine
Grief, Depression, and the DSM-5
chiatric treatment will go with-
out it because their depressive
symptoms will be reflexively at-
tributed to their grief under the
bereavement exclusion.
The concern is understand-
able, 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 pri-
mary care setting receive any treat-
ment for depression.3 But the ar-
gument that there is no essential
difference between grief-related
depression and clear-cut major
depression is contradicted by rig-
orous data. For example, a study
using data from the National Epi-
demiologic 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 de-
pression during the 3-year follow-
up than those without a history
of depression or those who had
only had bereavement-related de-
pression.4
Thus, it seems clear that de-
pressive symptoms in the context
of grief are fundamentally differ-
ent, in terms of course and prog-
nosis, from those of clinical de-
pression. 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 depres-
sion are obviously at high risk for
depressive recurrence in the con-
text of loss, as they would be in
 PERSPECTIVE Grief, Depression, and the DSM-5

the face of numerous stressors,
and they should be monitored
closely for worsening neurovege-
tative symptoms or the emergence
of suicidal or delusional thinking.
patients are seen by primary care
practitioners, it is critical that
such practitioners be skilled at
distinguishing between clinical
depression, which requires treat-
From the Department of Psychiatry, Weill
Medical College of Cornell University, New
York.
This article (10.1056/NEJMp1201794) was
updated on May 17, 2012, at NEJM.org.

We also know that 10 to 20% of
bereaved people do not get over
their grief easily and go on to de-
velop 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 re-
solves naturally on its own. Be-
cause the vast majority of be-
reaved and clinically depressed
ment, and uncomplicated grief,
which is an entirely normal emo-
tional response to loss. The med-
ical profession should normalize,
not medicalize, grief.
Editor’s note: On May 9, 2012, the APA an-
nounced 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.
Disclosure forms provided by the author
are available with the full text of this article
at NEJM.org.
1. Murphy SL, Xu J, Kochanek KD. Deaths:
preliminary data for 2010. Stat Rep 2012;60:
1-68 (http://www.cdc.gov/nchs/data/nvsr/
nvsr60/nvsr60_04.pdf).
2. Carey B. Grief could join list of disorders,
New York Times. January 24, 2012:A1.
3. Kessler RC, Berglund P, Demler O, et al. The
epidemiology of major depressive disorder:
results from the National Comorbidity Survey
Replication (NCS-R). JAMA 2003;289:3095-105.
4. Mojtabai R. Bereavement-related depres-
sive episodes: characteristics, 3-year course,
and implications for the DSM-5. Arch Gen
Psychiatry 2011;68:920-8.
5. Shear K, Frank E, Houck PR, Reynolds CF III.
Treatment of complicated grief: a randomized
controlled trial. JAMA 2005;293:2601-8.
Copyright © 2012 Massachusetts Medical Society.

n engl j med 366;20 nejm.org may 17, 2012 1857

The New England Journal of Medicine
Downloaded from nejm.org at UC SHARED JOURNAL COLLECTION on March 31, 2015. For personal use only. No other uses without permission.
Copyright © 2012 Massachusetts Medical Society. All rights reserved.