The Bereavement Exclusion and DSM-5: An Update and Commentary

The removal of the bereavement exclusion in the diagnosis of major depression was perhaps the most controversial change from DSM-IV to DSM-5. Critics have argued that removal of the bereavement exclusion will "medicalize" ordinary grief and encourage over-prescription of antidepressants. 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). Though bereavement-related grief and major depression share some features, they are distinct and distinguishable conditions. Bereavement does not "immunize" the patient against a major depressive episode, and is in fact a common precipitant of clinical depression. Recognizing major depression in the context of recent bereavement takes careful clinical judgment, and by no means implies that antidepressant treatment is warranted. But given the serious risks of unrecognized major depression-including suicide- eliminating the bereavement exclusion from DSM-5 was, on balance, a reasonable decision.