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Evidence that current diagnostic criteria used by psychiatrists and other mental health professionals could allow misdiagnosis of many individuals who are in fact suffering from normal sadness reactions to various losses analogous to grief after the death of a loved one is presented in an article in the April 2 issue of Archives of General Psychiatry.

The findings, presented by Jerome Wakefield, University Professor and professor of social work at New York University; Mark Schmitz, Temple University; Michael First, Columbia University; and Allan Horwitz, Rutgers University, indicate that current diagnostic criteria for Major Depressive Disorder (MDD), the most common condition treated by psychiatrists and other mental health professionals, might substantially overstate the number of people who have these conditions. These criteria currently diagnose the presence of depressive disorder by assessing whether the patient has certain symptoms, such as sadness, sleeplessness, and lack of appetite. The only exception to a diagnosis of disorder for people who display enough of these symptoms is when they occur during periods of bereavement after the loss of a loved one, as long as the symptoms are “uncomplicated,” that is, not especially severe or prolonged.

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However, a flaw in the current Diagnostic and Statistical Manual (DSM - IV) criteria for depressive disorder is that normal bereavement is the only exclusion from diagnosis. Other conditions of intense normal sadness that arise after stressors such as the end of a love affair, marital separation, diagnosis of serious illness in oneself or a loved one, or the loss of a valued job are not similarly excluded, even though they too often contain similar symptoms.

The study is the first to try to test whether this flaw does likely misclassify normal sadness as depressive disorder. It is also the first to attempt to rectify the flaw by taking the same procedures that the DSM itself uses for bereavement and applying those procedures to distinguish normal versus disordered reactions to other kinds of losses. It draws on data from the National Comorbidity Survey, an epidemiological study that uses DSM criteria to diagnose mental disorder in a large community sample that is representative of the American population.

Just as the DSM divides bereavement cases in to “uncomplicated” ones that are considered normal and the “complicated” ones with symptoms of unusual duration or severity that are considered disorders even though triggered by a real loss, the present study divides people who report experiencing life stressors other than bereavement into “uncomplicated” cases and “complicated” cases using the same criteria that the DSM applies only to bereavement. It compares the uncomplicated bereavement group to the uncomplicated other-loss group, and also compares the two uncomplicated groups to the two complicated categories, on many indicators that tend to imply the presence of a disorder, including the number of symptoms, the duration and recurrence of symptoms, suicide attempts, interference with life activities, and the use of psychiatric services.

The results indicate a striking similarity in the disorder indicators and the symptom profiles that arise after uncomplicated cases of grief and uncomplicated reactions to other losses, suggesting that these other reactions, like uncomplicated grief, are generally normal responses to loss. Likewise, complicated cases that arose after grief and complicated reactions to other losses had very comparable levels of disorder and symptom indictors, and both complicated categories were substantially higher on disorder indicators than either uncomplicated category. This provides striking support for the hypothesis that, just like grief, reactions to other losses divide into normal and disordered, and that uncomplicated reactions to other serious losses are likely predominantly non-disordered, whereas complicated reactions are likely predominantly disordered. Yet currently there is no provision to eliminate reactions to other losses from diagnosis, raising the possibility that normal individuals may be labeled as disordered.

How much difference might this make? Calculating the difference it would make if current DSM guidelines for distinguishing normal from disordered grief were systematically applied to reactions triggered by other losses, the researchers estimate that about 25% of persons in the community sample who are currently diagnosed with depressive disorders might, in fact, be experiencing intense normal sadness reactions to loss. Because current screening instruments that detect depression in primary care populations and in students do not use the context of loss to separate normal emotions of sadness from depressive mental disorders, actual clinical diagnoses of depression, as well as community prevalence figures, might also be inflated, possibly leading to the overmedicating of normal responses to loss.

The article in Archives of General Psychiatry supports the argument of a forthcoming book from Oxford University Press by Horwitz and Wakefield, The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder.