The removal of the bereavement exclusion in the DSM-5: exploring the evidence

Since 1980, the DSM-III and its various iterations through the DSM-IV-TR have systematically excluded individuals from the diagnosis of major depressive disorder if symptoms began within months after the death of a loved one (2 months in DSM-IV), unless the depressive syndrome was 'severely' impairing and/or accompanied by specific features. This criterion became known as the 'bereavement exclusion'. No other adverse life events were noted to negate the diagnosis of major depressive disorder if all other symptomatic, duration, severity and distress/impairment criteria were met. However, studies since the inception of the bereavement exclusion have shown that depressive syndromes occurring after bereavement share many of the same features as other, non-bereavement related depressions, tend to be chronic and/or recurrent if left untreated, interfere with the resolution of grief, and respond to treatment. Furthermore, the bereavement exclusion has had the unintended consequence of suggesting that grief should end in only 2 months, or that grief and major depressive disorder cannot co-occur. To prevent the denial of diagnosis and the consideration of sometimes much needed care, even after bereavement or other significant losses, the DSM-5 no longer contains the bereavement exclusion. Instead, the DSM-5 now permits the diagnosis of major depressive disorder after and during bereavement and includes a note and a comprehensive footnote in the major depressive episode criteria set to guide clinicians in making the diagnosis in this context. The decision to make this change was widely and publically debated and remains controversial. This article reports on the rationale for this decision and the way the DSM-5 now addresses the challenges of diagnosing major depressive disorder in the context of someone grieving the loss of a loved one.