A Guide to DSM-5

Bret S. Stetka, MD; Christoph U. Correll, MD

May 21, 2013

Removal of the Bereavement Exclusion From MDD

The Change

The bereavement exclusion in DSM-IV, which has been removed in DSM-5, was intended to exclude individuals experiencing depressive symptoms lasting less than 2 months after the death of a loved one from a diagnosis of MDD. The new edition characterizes bereavement as a severe psychological stressor that can incite a major depressive episode even shortly after the loss of a loved one.

The Implications

As detractors have pointed out, this contentious revision risks pathologizing a normal human process, grief. Individuals may be diagnosed with depression even in the absence of severe depression symptoms (ie, suicidal ideation) and even though their symptoms may be transient. Furthermore, in a recent article in World Psychiatry,^[13] Drs. Jerome Wakefield and Michael First call into question the validity of research supporting removing the exclusion, concluding, "...there is no scientific basis for removing the bereavement exclusion from the DSM-5."

Proponents of eliminating the exclusion argue that grief does not preclude the development of full-blown depression, and further that grief predisposes to MDD. A categorical exclusion of MDD for 2 months after the death of a loved one wrongly presumes that nobody can become seriously depressed while also grieving. Dr. Ronald Pies, Medscape columnist and Professor of Psychiatry at SUNY Upstate Medical University commented in a recent column, "There are...substantial differences between grief and MDD, and experienced clinicians will be able to tell the difference." Thus, it will be important for clinicians to continue to assess the quality, reactivity, and extent of the depressive symptoms and to diligently differentiate bereavement from MDD in clinical practice. If in doubt, pharmacologic treatment may need to be delayed to assess the trajectory of the symptoms, unless they are severe or dangerous.