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新研究结果显示，与丧亲之痛有关的重郁症，基本上与其他形式忧郁症相同，都是来自其他压力性的生活事件，显示这不应该被排除于标准的忧郁症诊断之外。
目前，精神疾患诊断与统计手册第四版（DSM-IV）将丧亲相关的忧郁症安排为一个特别的状态，宣称其与其他所有忧郁症疾患不同。然而，这些最新的发现挑战了这个主张。
来自圣地牙哥加州大学的研究共同作者Sidney Zisook医师表示，发生在失去挚爱者有关的忧郁症状，基本上与发生在任何其他负面事件或是丧失某些事情的本质是几乎相同的。
这项研究由里奇蒙维吉尼亚联邦大学医学院Kenneth S. Kendler医师发表于11月号美国精神医学期刊上。
Zisook医师表示，如果一个人的忧郁病况符合重郁症标准，应该严肃地被看待，且将其诊断为重郁症，并且给予治疗，而不是继续使用排除丧亲之痛的条款，或将其视为是“正常的悲伤”。
丧亲之痛是唯一被DSM-IV排除的一个造成压力的生活事件，为了确认正常的悲伤或是与其他压力性生活事件相关的重郁症，研究团队针对一个大型群众为基础的双胞胎样本进行研究。
他们找出82位确定有丧亲之痛相关忧郁症的个体，以及224位罹患与压力性生活事件，包括离婚/分居（167位）、疾病（36位）与失业（21位）相关忧郁症的个体。
【相似度超出了差异性】
总共有23位（28%）有丧亲之痛的个体符合DSM-IV正常悲伤的标准，但有同样数量的忧郁症病患并非与丧亲相关，55位（25%）个体也符合这些条件。
研究者报告，这两组在许多重要的方面都是相似的，包括暴露在标的事件的时间长度，严重受损的频率，以及这些事件的临床严重度。
作者写到，丧亲之痛相关的忧郁症以及与其他压力性事件相关之忧郁症的相似性是超过其差异的。我们无法指出，就如同DSM所预测的，符合丧亲之痛相关忧郁与正常悲伤相关的忧郁病例，在任何一方面是独特的。在那些状况之下，这些结果推翻继续使用DSM-IV中排除丧亲之痛的准则。
Zisook医师表示，治疗决定端看忧郁的严重性与持续性，以及病患的病史，因此不是每一个符合重郁症诊断标准且有丧亲之痛的个体都需要立刻接受药物治疗。
但是如果个体符合重郁症的诊断标准，你不必帮他一个忙，忽略他或是她的症状，并且说“喔，这只是正常的悲伤表现”；他表示，未经确认或是未受治疗的重郁症可能会有严重的结果。
【另一个观点】
由Jerome C. Wakefield博士领导的纽约大学研究团队也发现许多丧亲之痛相关忧郁症与其他压力性生活事件有关忧郁症之间的相同性（摘自Arch Gen Psychiatry. 2007;64:433-440），但是他们的结论是不同的。
不是屏弃排除丧亲之痛的条款，他们建议将这个排除条件延伸到所有非复杂性可能诱发忧郁发作的生活事件。
Wakefield博士向Medscape精神医学表示，丧亲之痛的排除太狭窄了，应该要延伸到涵盖相似没有太长、或是没有太严重的反应到其他重大生命中的压力源。
根据Wakefield博士表示，非复杂性的丧亲之痛显然不是疾病，但应该要与其他压力源的非复杂性反应同等看待。
【对立的建议】
义大利那不勒斯大学的Mario Maj博士在随后的评论中表示，这两组研究者的建议是完全相反的。
他写到，这些相反的建议来自于同样的研究，可能使我们的领域及好社会舆论分歧长达好几年。
当然，两个建议都有重大的治疗涵义。一方面，其风险是医疗化适当的反应，因而打乱个别化反应的过程。另一方面，其风险在于剥夺一个人在充满忧郁症状时可能需要的治疗。
Maj博士进一步表示，以目前对于这种状况的了解，一个人在生命中发生重大事件时，以严重、持久及损伤的标准来诊断严重忧郁症是不明智的。
另一方面，DSM-V诊断重郁症移除丧亲排除条款，可以看做精神医学企图病态化正常人类心理过程的一步，这还需要更强、及更明确的研究证据。
然而，Maj博士相信由DSM移除丧亲排除条款是可行的，而目前的研究在不同的族群及场景，包括年轻人与老人、失去亲密的亲人与朋友等等，都应该被确效。
此研究是由国家健康协会授权以及圣地牙哥健康照护体系提供本研究资金。Zisook博士接受PamLab及Aspect医疗体系赞助，且接受GlaxoSmithKline药厂、Forest Pharmaceuticals药厂及Wyeth-Ayerst Laboratories研究室的演讲报酬。本研究其他作者及Maj博士并未接受相关金融赞助。
Bereavement-Related Depression Identical to Other Depression Types
By Marlene Busko
Medscape Medical News
Major depression related to bereavement is essentially identical to major depression brought on by other stressful life events, suggesting that it should not be excluded from standard depression diagnoses, new research suggests.
Currently, the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), assigns special status to bereavement-related depression, claiming it is distinct for all other depressive episodes. However, these latest findings challenge this assertion.
"Depression that occurs in the context of the loss of a loved one is essentially identical to depression that occurs in the context of any other negative event or loss," study coauthor Sidney Zisook, MD, from the University of California at San Diego, told Medscape Psychiatry.
The study, led by Kenneth S. Kendler, MD, from Virginia Commonwealth University Medical School, in Richmond, was published in the November issue of the American Journal of Psychiatry.
"If a bereaved person's depression otherwise meets criteria for major depression, it should be taken seriously, diagnosed as major depression, and treated accordingly, rather than continuing to use the bereavement-exclusion rule and treating this as 'normal grief'," said Dr. Zisook.
Bereavement is the only predisposing stressful life event that is singled out in the DSM-IV. To determine the validity of distinguishing normal grief from major depression associated with other stressful life events, the researchers examined a large population-based sample of twins.
They identified 82 individuals with confirmed bereavement-related depression and 224 individuals with depression related to stressful life events, including divorce/separation (167), illness (36), and job loss (21).
Similarities Outweigh Differences
A total of 23 people (28%) with bereavement-related depression met the DSM-IV criteria for normal grief, but a similar proportion of people with depression unrelated to bereavement, 55 people (25%), also met these criteria.
"The 2 groups were similar in many important ways, including duration of the index episode, the frequency of severe impairment, the clinical severity of the episode," the researchers report.
"The similarities of bereavement-related depression and depression related to other stressful life events far outweigh their differences. We were unable to show, as predicted by DSM, that cases of depression meeting criteria for both bereavement-related depression and 'normal grief' were unique in any way. On their face, these results argue against the continued use of the 'bereavement-exclusion rule' in the DSM-V," the authors write.
Treatment decisions depend on the severity and persistence of the depression, as well as the patient's history, so not every bereaved individual who meets the criteria for major depression needs to be treated with medications right away, said Dr. Zisook.
"But if the individual meets the criteria for major depression, you don't do him or her a favor by ignoring the symptoms and saying, 'Oh, that's just normal grief.' Unrecognized or untreated major depression can have serious consequences," he said.
Another Point of View
Investigators at New York University, led by Jerome C. Wakefield, PhD, DSW, also found many more similarities than differences between bereavement-related depression and depression related to other stressful life events (Arch Gen Psychiatry. 2007;64:433-440), but came to a "dramatically different" conclusion.
Instead of dropping the bereavement-exclusion rule, they suggest extending the exclusion to all episodes of uncomplicated life-event-precipitated depressive episodes.
"The bereavement exclusion is too narrow," Dr. Wakefield told Medscape Psychiatry. "It ought to be extended to cover similar not-too-long, not-too-severe reactions to other major stressors in life."
According to Dr. Wakefield, uncomplicated bereavement is clearly not disordered, and looks similar to uncomplicated reactions to other stressors.
Opposite Proposals
In an accompanying editorial, Mario Maj, MD, from the University of Naples, in Italy, says that the conflicting recommendations by the 2 research groups are likely to be divisive.
"These opposite proposals based on the same research are likely to divide our field and the public opinion for several years," he writes.
"Of course, both proposals have significant treatment implications. On the one hand, the risk is to medicalize an adaptive response, thus disrupting the individual's coping processes. On the other, the risk is to deprive a person with full depressive syndrome of a treatment that may be needed."
Dr. Maj continues: "At the present state of knowledge, it may be therefore unwise to disallow the diagnosis of major depression in a person meeting the severity, duration, and impairment criteria for that diagnosis just because the depressive state occurs in the context of a significant life event."
"On the other hand, the removal of the bereavement-exclusion criterion from the DSM-V diagnosis of major depression — a move that may be perceived as a further step in psychiatry's attempt to pathologize normal human processes — requires strong and unequivocal research evidence," Dr. Maj notes.
However, Dr. Maj believes that before a decision to remove the bereavement-exclusion criterion from the future editions of the DSM is made, the results of the current study should be validated in various groups and scenarios — young vs old, impact of losing a close relative vs a friend, etc.
The study was supported by NIH grants and the VA San Diego Healthcare System. Dr. Zisook has received research support from PamLab and Aspect Medical Systems, and has received speaking honoraria from GlaxoSmithKline, Forest Pharmaceuticals, AstraZeneca, and Wyeth-Ayerst Laboratories. The other study authors and Dr. Maj have disclosed no relevant financial relationships.
Am J Psychiatry. 2008; 165:1373-1375, 1449-1445.