The DSM-5 and the bereavement exclusion: a call for critical evaluation.

The discipline of social work has long prided itself on taking a holistic view of human suffering and well-being and for advocating for conditions that enhance the quality of life for vulnerable populations. Yet, as others have pointed out (Carney, 2012), social workers have remained mostly silent when it comes to the changes proposed for the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This is perplexing, given the debate this revision process has sparked in the mental health professions. In addition, social workers provide a substantial portion of mental health services in the United States, typically using the DSM (Frazer, Westhuis, Daley, & Phillips, 2009), and any changes to the manual will likely have farreaching effects on the individuals social workers serve and on the profession as a whole. For this reason, the DSM-5 changes require critical evaluation from social work. Though a wide range of changes has been proposed, we wish to consider just one aspect that has generated heated debate and public outcry: a change to the criteria for major depressive disorder (MDD). Whereas DSM-IV offers a bereavement exclusion that discourages the use of this diagnosis within a two-month postdeath period, DSM-5 proposes to eliminate this exclusion and allow a diagnosis of MDD two weeks after a death. We consider this proposal in light of its potential effect on bereaved parents, who constitute an especially vulnerable population socially, emotionally, and even economically (Song, Floyd, Mailick Seltzer, Greenberg, & Hong, 2010), due to the traumatic nature of infant and child death. Although bereavement is widely recognized as a unique life event, the effects of loss must be considered within the context of individual experiences such as the relationship to the deceased and the circumstances surrounding the death. Among bereaved parents there are many variables that affect the intensity and duration of grief, such as the degree and quality of attachment (Kreicbergs, Valdimarsdottir, Onelov, Henter, & Steineck, 2004), manner of death (Arnold, Gemma, & Cushman, 2005), religious affiliation (Wijngaards-de Meij et al., 2005), ethnicity (Laurie & Neimeyer, 2008), prior history of mental disorder (Hensley, 2006), concordant partner responses (Dyregrov & Dyregrov, 1999), and perceived level of social support (Cacciatore, Schnebly, & Froen, 2009; Mann, McKeown, Bacon, Vesselinov, & Bush, 2008). The current edition of the DSM fails to take many of these factors into consideration, and instead relies on an arbitrary two-month cutoff point before symptoms of grief contribute toward a diagnosis of MDD. However, it is well accepted that grief often lasts well beyond two months (Shuchter & Zisook, 1993), even under the best of circumstances, and that there is a significant overlap with depressive symptoms. Symptoms common to both states include sleep disturbances, fatigue, anhedonia, changes in appetite, and enduring emotional distress. These effects may be especially pronounced in bereaved parents, and feelings of worthlessness or shame and suicidal ideation, also considered symptoms of depression, are not uncommon in this population (DeFrain, 1986; Murphy, Tapper, Johnson, & Lohan, 2003;Qin &Mortensen, 2003). Because of their intense reactions, bereaved parents are at high risk of having their understandable suffering misinterpreted as signs of a mental disorder if the bereavement exclusion is eliminated. The change to DSM-5 would allow a diagnosis of MDD as early as two weeks following the death of a child. This move reflects a wider trend of narrowing the bereavement exclusion over time, as the DSM-III allowed up to one year for the bereavement