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Normal vs. disordered bereavement-related depression: are the differences real or tautological?

Authors

  • J. C. Wakefield,

    1. Silver School of Social Work, New York University, New York, NY
    2. Department of Psychiatry, School of Medicine, New York University, New York, NY
    3. Institute for Social and Psychiatric Initiatives–Research, Education and Services (InSPIRES), New York University, New York, NY
    4. Division of Clinical Phenomenology, Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY
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  • M. F. Schmitz

    1. Institute for Social and Psychiatric Initiatives–Research, Education and Services (InSPIRES), New York University, New York, NY
    2. School of Social Work, Temple University, Philadelphia, PA, USA
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Jerome C. Wakefield, Silver School of Social Work, New York University, 1 Washington Square North, New York, NY 10003, USA.
E-mail: wakefield@nyu.edu

Abstract

Objective:  To evaluate whether the DSM distinction between uncomplicated (normal) and complicated (disordered) bereavement-related depression (BRD) has discriminant validity on a range of pathology indicators. The DSM’s major depression bereavement exclusion (BE) excludes BRDs from diagnosis when they are uncomplicated (defined by brief duration, non-severe impairment, and lack of certain pathosuggestive symptoms) but classifies all other (“complicated”) BRDs as major depression. A previous report seemed to support the uncomplicated/complicated distinction’s discriminant validity. However, those arguing for eliminating the BE from DSM-5 dismiss the findings as ‘tautological,’ attributing the validator differences to definitional biases (e.g. ‘uncomplicated’ requires ‘no suicidal ideation,’ yet ‘lifetime suicide attempt’ was a validator). This study empirically tests whether the uncomplicated/complicated differences are real or tautological.

Method:  Using National Comorbidity Survey data, confounds between definitional criteria for ‘uncomplicated’ and pathology validators were identified and corrected by deleting the biasing criteria and recalculating the corresponding validator’s outcome.

Results:  Six validators (interference with life, suicide attempt, melancholic depression, duration, hospitalization, and number of symptoms) were reanalyzed using unbiased definitions for ‘uncomplicated.’ All still yielded significantly lower pathology levels for uncomplicated BRDs, disconfirming the ‘tautology’ hypothesis. Regression analysis revealed that ‘uncomplicated’ offered incremental validity over severity alone in predicting pathology, so ‘uncomplicated’ cannot be equated with ‘mild.’

Conclusion:  Uncomplicated BRDs’ lower pathology validator levels are because of real syndromal differences, not definitional tautologies, supporting the BE’s validity.

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