Depression and the pitfalls of causality: implications for DSM-V

J Affect Disord. 2009 Jul;116(1-2):1-3. doi: 10.1016/j.jad.2008.11.009. Epub 2008 Dec 4.


Causal narratives are often invoked as explanations for depressive episodes, and some have argued that even serious depressive symptoms in the context of recent bereavement should not be considered a psychiatric disorder. However, the limited data we have suggest that "bereavement-related depression" does not significantly differ from non-bereavement-related major depression, in terms of symptom picture, risk of recurrence, or clinical outcome. Furthermore, the notion of establishing a psychosocial precipitant (such as loss of a loved one) as the "cause" of a patient's depression fails to consider several confounding variables. The patient may have an inaccurate or distorted recollection of depression onset, or be unaware of pre-existing medical and neurological conditions that are strongly "driving" the depression. Moreover, judgments regarding how "proportionate" or "disproportionate" a person's depressive symptoms are in relation to a putative "precipitant" are fraught with uncertainties and may be influenced by cultural biases. Until we have controlled, longitudinal data showing that "bereavement-related depression" differs significantly from non-bereavement-related major depression, it is premature and risky to alter our current "cause-neutral" diagnostic framework. Indeed, there are compelling reasons to eliminate the so-called bereavement exclusion from DSM-V.

Publication types

  • Review

MeSH terms

  • Bereavement*
  • Depression / diagnosis
  • Depression / psychology*
  • Depressive Disorder, Major / diagnosis
  • Depressive Disorder, Major / psychology*
  • Diagnosis, Differential
  • Diagnostic and Statistical Manual of Mental Disorders*
  • Humans
  • Psychiatric Status Rating Scales
  • Risk Factors