A 28-year-old man comes to the office saying, "I'm just not feeling like myself." This change began soon after his older brother died of cancer 3 months ago. The patient feels sad and has lost interest in work and going out with friends on weekends. He falls asleep relatively easily at night but awakens very early in the morning and is unable to fall back asleep. The patient feels "very down," especially when he first wakes up, but says that his mood improves a little during the day when he is busy. His poor energy and concentration have started to affect his performance at work, and he frequently thinks that, "I should just quit because I am bringing everyone down." He has been eating less and has lost 5.4 kg (12 lb) over the past few weeks. The patient has had no suicidal thoughts. He has no psychiatric history other than counseling as a teenager when his parents divorced. The patient mentions that he had been close to his brother when they were growing up, but they drifted apart as adults. Which of the following is the most likely diagnosis for this patient?
Major depressive episode & grief reaction | |
Major depressive episode | Grief reaction |
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Although this patient's depressive symptoms developed in response to the stressor of bereavement, his symptoms are sufficient in number, duration, and severity to meet diagnostic criteria for a major depressive episode (ie, depressed mood, loss of interest, early morning awakening, weight loss, low energy, impaired concentration lasting ≥2 weeks). Patients with ≥1 major depressive episode and no history of mania or hypomania are diagnosed with major depressive disorder (MDD). DSM-5 allows for the diagnosis of MDD during the bereavement period because evidence has shown that bereavement-related major depression and major depression not related to bereavement have a similar course and response to treatment. The death of a loved one is similar to any other serious stressor that can trigger a major depressive episode.
Major depression can be difficult to differentiate from acute grief. In a normal grief reaction, sadness is typically focused on the deceased and decreases in intensity over several weeks, with intermittent waves of grief mixed with positive memories (Choice D). A major depressive episode involves more persistent sadness and pervasive anhedonia (as in this patient). Excessive guilt, self-critical ruminations, and suicidality related to feelings of worthlessness and hopelessness can also help distinguish MDD from normal grief.
(Choice A) Acute stress disorder develops within one month of a traumatic event and is characterized by intrusive re-experiencing (eg, flashbacks, intense memories), negative mood and cognitions, avoidance, and hyperarousal.
(Choice B) Adjustment disorder with depressed mood is characterized by depressive symptoms that develop in response to a stressor. However, symptoms should not represent normal bereavement and cannot be diagnosed when criteria are met for another disorder, such as MDD in this patient.
(Choice E) Persistent complex bereavement disorder (also called complicated grief) is characterized by persistent yearning for the deceased and prolonged emotional pain related to the loss. It is accompanied by maladaptive, ruminative thoughts and dysfunctional behaviors. This patient's depression does not revolve around yearning for his brother.
Educational objective:
Major depressive disorder can be diagnosed if depressive symptoms following the loss of a loved one are sufficiently severe to meet diagnostic criteria. Compared to normal grief, major depression is associated with more persistent and pervasive sadness, feelings of hopelessness and worthlessness, and suicidal ideation.