Gilman, Stephen E.
From the Departments of Social and Behavioral Sciences and Epidemiology, Harvard School of Public Health, Boston, MA; and Department of Psychiatry, Massachusetts General Hospital, Boston, MA.
Correspondence: Stephen E. Gilman, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115. E-mail: email@example.com.
“A correlation of melancholia and mourning seems justified by the general picture of the two conditions. Moreover, wherever it is possible to discern the external influences in life which have brought each of them about, this exciting cause proves to be the same in both. Mourning is regularly the reaction to the loss of a loved person, or to the loss of some abstraction which has taken the place of one, such as fatherland, liberty, an ideal, and so on. As an effect of the same influences, melancholia instead of a state of grief develops in some people, whom we consequently suspect of a morbid pathological disposition. It is also well worth notice that, although grief involves grave departures from the normal attitude to life, it never occurs to us to regard it as a morbid condition and hand the mourner over to medical treatment. We rest assured that after a lapse of time it will be overcome, and we look upon any interference with it as inadvisable or even harmful.”
Sigmund Freud, 1917
The connection of loss with the experience of depressive illness is a longstanding truth in modern psychiatry, as illustrated by Freud’s comments above.1 p. 283 Beyond resonating with our own personal experiences, the psychiatric—as well as physical—consequences of bereavement are well established by empirical evidence.2
One might then wonder, what new information is there in Appel et al’s study3 of the association between the loss of a parent before age 30 and subsequent hospitalization for an affective disorder? I would say Appel et al’s study advances our understanding of loss and depression in two respects: 1) it demonstrates that the association between parental death and depression exists independently from the well-known, intergenerational transmission of psychiatric disorders;4 and 2) it demonstrates that the mental health consequences of bereavement are potentially so severe as to require treatment in a hospital setting, and extend beyond major depression to bipolar disorder (ie, mania). Thus, Appel et al’s study addresses both the causal connection between loss and depression and has implications for the nosological distinction between normal and pathological depression, which Freud addressed in the passage above almost a century ago and which remains a controversy in clinical psychiatry.5
The Causal Status of Loss and Depression
Using data on parental hospitalization for a psychiatric disorder, Appel et al were able to adjust for the presence of parental psychopathology in their analyses of parental loss and depression. They claim that this adjustment accounts for confounding due to shared genetic predisposition. It might, in part, but I think this claim is both too optimistic and too narrow. I say too optimistic because adjustment for parental disorder only partially controls for the heritable aspects of psychopathology,6 and too narrow because adjustment for parental disorders may account for the documented associations between depression and mortality, which involve a range of nongenetic factors (eg, smoking).7,8 Although residual confounding from undiagnosed or untreated parental depression remains a concern, the authors’ approach nonetheless represents an important advance.
Appel et al’s estimate of the association between parental death and depression does not account for the decay in risk for depression that takes place in the years following a loss or other types of adversity.9,10 The estimate also does not account for the impact of parental death on the development of depression before age 15; this is a matter of concern because prior research indicates that the loss of a parent is a particularly strong risk factor for juvenile onset depression.11
The Nosological Status of Loss and Depression
Distinguishing between “normal,” nondisordered reactions to the loss of a loved one and the psychiatric condition of major depression (eg, “major depressive disorder”)12 has been a challenge since at least Freud’s time and has reemerged as a controversy in clinical psychiatry.13 Since the publication in 1980 of the 3rd edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-III),14 depressive episodes that would otherwise qualify for a diagnosis of major depressive disorder were excluded from a diagnosis unless they were especially prolonged or severe. No longer. Some warn that the impending removal of the “bereavement exclusion” from the forthcoming DSM-5 criteria for major depressive disorder will lead to a massive pathologizing of normal sadness.15 Appel et al’s study is informative because it demonstrates that experiencing parental death at an early age has mental health consequences that can be severe enough to require hospitalization. Their findings support striking the bereavement exclusion from the DSM, thereby facilitating psychiatric treatment for those who experience a major depressive episode following the loss of a loved one.
Above, Freud warned against interfering with the natural course of mourning and reserving treatment for “melancholia” (ie, major depressive disorder). Freud’s warning assumes we can validly distinguish between mourning and depression; it is very difficult to do so based on symptoms alone,16 and the DSM-IV framework for differentiating between bereavement-related depressive episodes that should and should not qualify for a psychiatric diagnosis had questionable validity.17,18 Appel et al’s findings, considered in the context of existing evidence that those with bereavement-related depressive episodes can benefit from psychiatric treatments,19–21 suggest that early parental death is a risk for highly impairing forms of psychopathology and identifies a group that could likely benefit from preventive intervention.22 Additional work is needed to carefully weigh the risks and benefits of intervening among bereaved persons and determine the optimal timing of intervention—particularly among children.
ABOUT THE AUTHOR
STEPHEN GILMAN is social and psychiatric epidemiologist. His research program addresses the early-life origins and intergenerational transmission of major depression and social inequalities in depression across the life course. His work also focuses on outcomes of depression including bipolar disorder, substance-use disorders, and mortality.
1. Radden J The Nature of Melancholy: From Aristotle to Kristeva. 2000 Oxford, New York Oxford University Press
2. Stroebe M, Schut H, Stroebe W. Health outcomes of bereavement. Lancet. 2007;370:1960–1973
3. Appel CW, Johansen C, Deltour I, et al. Early parental death and risk of hospitalization for affective disorder in adulthood. Epidemology. 2013;24:608–615
4. Weissman MM, Wickramaratne P, Nomura Y, et al. Families at high and low risk for depression: a 3-generation study. Arch Gen Psychiatry. 2005;62:29–36
5. Pies RW. Depression and the pitfalls of causality: implications for DSM-V. J Affect Disord. 2009;116:1–3
6. Kendler KS. Familial risk factors and the familial aggregation of psychiatric disorders. Psychol Med. 1990;20:311–319
7. Cuijpers P, Smit F. Excess mortality in depression: a meta-analysis of community studies. J Affect Disord. 2002;72:227–236
8. Chaiton MO, Cohen JE, O’Loughlin J, Rehm J. A systematic review of longitudinal studies on the association between depression and smoking in adolescents. BMC Public Health. 2009;9:356
9. Kendler KS, Sheth K, Gardner CO, Prescott CA. Childhood parental loss and risk for first-onset of major depression and alcohol dependence: the time-decay of risk and sex differences. Psychol Med. 2002;32:1187–1194
10. Surtees PG, Wainwright NW. Surviving adversity: event decay, vulnerability and the onset of anxiety and depressive disorder. Eur Arch Psychiatry Clin Neurosci. 1999;249:86–95
11. Jaffee SR, Moffitt TE, Caspi A, Fombonne E, Poulton R, Martin J. Differences in early childhood risk factors for juvenile-onset and adult-onset depression. Arch Gen Psychiatry. 2002;59:215–222
12. American Psychiatric Association. Task Force on DSM-IV. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 20004th ed Washington, DC American Psychiatric Association
13. Horwitz AV, Wakefield JC The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. 2007 New York Oxford University Press
14. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-III. 19803rd ed Washington, DC American Psychiatric Association
15. Wakefield JC. Should uncomplicated bereavement-related depression be reclassified as a disorder in the DSM-5? Response to Kenneth S. Kendler’s statement defending the proposal to eliminate the bereavement exclusion. J Nerv Ment Dis. 2011;199:203–208
16. Clayton PJ, Herjanic M, Murphy GE, Woodruff R Jr. Mourning and depression: their similarities and differences. Can Psychiatr Assoc J. 1974;19:309–312
17. Gilman SE, Breslau J, Trinh NH, Fava M, Murphy JM, Smoller JW. Bereavement and the diagnosis of major depressive episode in the National Epidemiologic Survey on Alcohol and Related Conditions. JClin Psychiatry. 2012;73:208–215
18. Gilman SE, Breslau J, Trinh NH, Fava M, Murphy JM, Smoller JW. Epidemiologic evidence concerning the bereavement exclusion in major depression. Arch Gen Psychiatry. 2012;69:1179–1180 author reply 1180.
19. Hensley PL, Slonimski CK, Uhlenhuth EH, Clayton PJ. Escitalopram: an open-label study of bereavement-related depression and grief. J Affect Disord. 2009;113:142–149
20. Reynolds CF 3rd, Miller MD, Pasternak RE, et al. Treatment of bereavement-related major depressive episodes in later life: a controlled study of acute and continuation treatment with nortriptyline and interpersonal psychotherapy. Am J Psychiatry. 1999;156:202–208
21. Zisook S, Shuchter SR, Pedrelli P, Sable J, Deaciuc SC. Bupropion sustained release for bereavement: results of an open trial. J Clin Psychiatry. 2001;62:227–230
22. O’Connell ME, Boat TF, Warner KENational Research Council (US) and. Institute of Medicine (US) Committee on Prevention of Mental Disorders and Substance Abuse Among Children, Youth, and Young Adults. . Research Advances and Promising Interventions. In: Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. 2009 Washington, DC National Academies Press