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Commentary: The Causal and Nosological Status of Loss in Major Depression

Gilman, Stephen E.

doi: 10.1097/EDE.0b013e3182953dcc

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:

“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

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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

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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.

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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.

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