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

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.