Grief and Major Depression—Controversy Over Changes in DSM-5 Diagnostic Criteria.

In May 2013, the American Psychiatric Association released the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).1 One of the more controversial revisions in the DSM-5 is the elimination of the bereavement exclusion criterion for major depressive disorder (MDD), suggesting to some that grief is not a normal process. Within the DSM-IV, text revision,2 persons who experienced the death of a loved one and who had a depressed mood would not be diagnosed with MDD unless symptoms persisted beyond two months or were characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. In the DSM-5, a note replaces what has traditionally been referred to as the bereavement exclusion criterion, or criterion E, for MDD in the DSM-IV, text revision. The note suggests that responses to any significant loss may include symptoms resembling a depressive episode, and although they may be understandable or appropriate to the loss, the presence of a major depressive episode should be considered carefully. In a footnote, the DSM-5 provides additional guidance on how to differentiate grief from MDD. To allow for diagnostic flexibility, the DSM-5 provides another option for noting normal reactions to the death of a loved one by including uncomplicated bereavement in the chapter titled “Other Conditions That May Be a Focus of Clinical Attention” (V62.82). Table 1 provides information on differentiating normal bereavement from a major depressive episode.1,3-5 Several reasons have been proffered for eliminating the bereavement exclusion criterion. These include: (1) removing the implication that bereavement typically lasts only two months; (2) recognizing bereavement as a severe psychological stressor that can precipitate MDD in vulnerable persons; (3) understanding that bereavement-related major depression is genetically influenced and is associated with similar personality characteristics, patterns of comorbidity, course, and Editorials