Unfortunately, these override features did not address those bereaved patients whose depressive symptoms were indeed severe, but who did not “qualify” for the specific override criteria (e.g., bereaved persons with profoundly impaired concentration, significant weight loss, or severe insomnia). It is true that the DSM-IV criteria provided a way to “override” the bereavement exclusion, (e.g., if the depressed, bereaved patient were psychotic, suicidal, psychomotorically slowed, preoccupied with feelings of worthlessness, or functioning very poorly in daily life).
4 In such a complex associational context, which factor or factors should be judged “causal”? And how would the old (DSM-IV) bereavement exclusion rules apply? The “exclusion” principle also fails to recognize that MDD is often a highly over-determined process, involving multiple, interacting causes (e.g., someone who develops a major depressive syndrome a few weeks after a loved one’s death may also be depressed owing to concomitant hypothyroidism, pancreatic cancer, marital problems, or a recent setback in business). 3 Disqualifying a patient from a diagnosis of major depression simply because the clinical picture emerges after the death of a loved one risks closing the door on potentially life-saving interventions. The bereavement exclusion was eliminated from the DSM-5 for two main reasons: 1) there have never been any adequately controlled, clinical studies showing that major depressive syndromes following bereavement differ in nature, course, or outcome from depression of equal severity in any other context-or from MDD appearing “out of the blue ” 2 and 2) major depression is a potentially lethal disorder, with an overall suicide rate of about four percent. Indeed, grief and depression-despite some overlapping symptoms, like sadness, sleep disturbance and decreased appetite-are distinct constructs, and one does not preclude the other. Put another way: DSM-5 recognizes that bereavement does not immunize the patient against major depression, and often precipitates it.
In truth, the DSM-5 criteria for major depressive disorder (MDD) merely say that the subset of persons who meet the full symptom-duration-severity criteria for major depression within the first few weeks after bereavement (i.e., the death of a loved one) will no longer be excluded from the set of all persons with major depression-as many would have been-under DSM-IVs exclusion guidelines. While I was not directly involved with the DSM-5 mood disorders work group, my colleagues and I were participants in a sometimes rancorous debate, 1, 2 often fueled by sensational or misleading reports in the lay media for example, lay media headlines included claims such as, “Psychiatrists want to make normal grief a mental disorder!” and “DSM-5 medicalizes mourning.” Without question, this was one of the most contentious decisions the DSM-5 work groups made-and, by some lights, the most controversial decision by the American Psychiatric Association (APA) since homosexuality was removed from the list of psychiatric disorders in 1973.
But given the serious risks of unrecognized major depression-including suicide- eliminating the bereavement exclusion from DSM-5 was, on balance, a reasonable decision.Ĭontroversy continues to surround the removal of the so-called “bereavement exclusion,” (BE) from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Recognizing major depression in the context of recent bereavement takes careful clinical judgment, and by no means implies that antidepressant treatment is warranted. Bereavement does not “immunize” the patient against a major depressive episode, and is in fact a common precipitant of clinical depression. Though bereavement-related grief and major depression share some features, they are distinct and distinguishable conditions.
Supporters of the DSM-5’s decision argue that there is no clinical or scientific basis for “excluding” patients from a diagnosis of major depression simply because the condition occurs shortly after the death of a loved one (bereavement). Critics have argued that removal of the bereavement exclusion will “medicalize” ordinary grief and encourage over-prescription of antidepressants. The removal of the bereavement exclusion in the diagnosis of major depression was perhaps the most controversial change from DSM-IV to DSM-5.