Bereavement is different: A multinational bereavement symptom model validation

•When diagnosing major depression it is still a clinical responsibility to rule out normal grief.•In multinational epidemiological samples bereavement symptoms differ from other depression.•A symptom-based model has moderate to good bereavement status discrimination properties.•Grief linked depression ostensibly a clinical disorder often resembles normal grief.•Check-box approach to diagnosing major depression risks pathologizing normal grief. Clinicians need to rule out an appropriate grief reaction when diagnosing major depression. This study identifies symptom differences by bereavement status and validates a symptom model of bereavement. Symptom features from six national cross-sectional epidemiological samples were analyzed and estimates pooled. Crying often, thinking of death, appetite loss, waking up early, trouble sleeping, and depending on others were significantly more likely in the bereaved. Symptoms of thinking of or attempting suicide, feeling one would be better off dead or wanting to die, worthlessness, social conflict, worthlessness with difficulty making decisions, being discouraged, feeling less than others, being troubled, not coping, feeling hopeless, sleeping more, being upset and history of an anxiety disorder were all significantly less likely among the bereaved. Moderate to good model discrimination effect sizes were found. Good model performance was found when narrowly defined complicated bereavement cases were excluded. On the whole the bereaved are more likely to report symptoms consistent with a normal grief reaction. As depression screening becomes the norm in primary care, normal grief that meets Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) symptom criteria for a MDE likely has a high risk of being diagnosed inappropriately as pathological depression.