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After Bereavement, Is It Normal Grief or Major Depression?

After GriefFollowing the death of a loved one, the relationship between grief and depression begins to blur. In fact, it has become one of the most debated topics in psychiatry, [1] as whether or not the bereavement exclusion in DSM-IV should be eliminated in DSM-5 has created quite the discussion. Upstate Medical University Professor of Psychiatry Ronald W. Pies, MD believes that there is no basis for keeping the bereavement exclusion, stating that it confuses clinicians and hinders diagnosis and treatment of depression.[2] However, the opposing side believes that eliminating the bereavement exclusion will only “medicalize normal grief” and cause clinicians to further overprescribe antidepressants.2 Therefore, in an effort to aid clinicians in determining between grief and major depression, Pies has developed an assessment tool, which he explains in his article “After Bereavement, Is It Normal Grief or Major Depression?” 2

Pies has developed the Post-Bereavement Phenomenology Inventory (PBPI), an assessment tool based upon the premise that the DSM-IV symptom checklists do not allow for a complete understanding of the different views of grief and major depression.[3] Pies states that this tool is neither a categorical nor a dimensional model of evaluation, but instead, it is an example of prototype matching.[4] It may be that the PBPI is tailored to assess a patient’s response to bereavement; however, Pies hopes that it will one day be used to assess other major losses, such as divorce, job loss, and relationship breakups.2

To further introduce the role of the PBPI, Pies offers five important points. First, Pies is offering the instrument to clinicians without it’s validation by clinical studies. Also, the PBPI does not replace the DSM-IV diagnostic approach to either bereavement or major depression, and the instrument is not made for forensic assessments.2 Second, the PBPI was not made to replace a full psychiatric evaluation or validated screening tools.2 Third, Pies states that the PBPI does not currently have a scoring system, but homes to have one in the future.2 Fourth, Pies states that the instrument is not a diagnostic tool, but is meant to raise or lower a clinician’s suspicion that a patient is experiencing major depression and not just grieving.2

Therefore, as there is no scoring mechanism thus far for the PBPI, Pies states that left-side versus right-side answers are the key to understanding a patient’s response. Patients who answer mostly left-sided are more likely to have depression, and are at a higher risk of suicide and psychiatric hospitalization than patients who answer mostly right-sided.2 Patients who answer mostly right-sided are more likely to be experiencing normal grief.2 There is the possibility that answers may be a mix of left- and right-sided, which may signify complicated grief; however, patients who check off the left-sided response to item eight (“persistent thoughts or impulses about ending my life”) require immediate medical attention, despite the number of right-sided responses checked.2 It is also possible for a patient to shift from left-sided responses to right-sided responses over time; therefore, giving a patient the PBPI several times may help with ongoing assessment.2

Overall, Pies hopes that the PBPI will aid clinicians in a deeper understanding of a patient’s current psychiatric state. To view a copy of the PBPI, please visit http://www.psychiatrictimes.com/display/article/10168/2035804



[1] Carey B. Grief could join list of disorders. New York Times. January 24, 2012. http://www.nytimes.com/2012/01/25/health/depressions-criteria-may-be-changed-to-include-grieving.htm

[2] Pies, R.W. After Bereavement, Is It Normal Grief or Major Depression. Psychiatric Times. February 21, 2012. http://www.psychiatrictimes.com/display/article/10168/2035804

[3] Zisook S, Shear K. Grief and bereavement: what psychiatrists need to know. World Psychiatry. 2009;8:67-74.

[4] Zimmerman M, Galione JN, Ruggero CJ, et al. A different approach toward screening for bipolar disorder: the prototype matching method. Compr Psychiatry. 2010;51:340-346.

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