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Why did the DSM-5 Remove the Bereavement Exclusion from Depression? Is it Bad?
The fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is due out in May and has been in the works for 14 years. The DSM could be considered the “bible” of mental illness as it’s the book that outlines the criteria for every recognized mental illness.
And this revision has been controversial. In one respect, I feel awfully bad for the professionals who have been working for 14 years to improve the way mental illnesses are diagnosed. What they have been receiving is overwhelmingly negative feedback.
On the other hand, at first blush some of the changes don’t seem to make sense and public debate on these issues is beneficial.
One of the most controversial changes has been the removal of the bereavement exclusion with regards to depression.
What is the Bereavement Exclusion?
In the DSM-IV-TR included a “bereavement exclusion” in the diagnosis of depression. What this meant was that a person could show the symptoms of depression but if it was two months after the death of a loved one, it wouldn’t be diagnosed as depression. After this period, depression could be diagnosed.
Intuitively, this makes sense. People naturally grieve a death and this grief could look like depression.
Why was the Bereavement Exclusion Removed?
A lot has been said about the removal of the bereavement exclusion and most of this feedback has been negative. Psychiatrists worry that this removal could lead to pathologizing normal grief and overdiagnosis. Of course, overdiagnosis could lead to the use of medications in inappropriate ways.
But the bereavement exclusion was removed for several reasons, determined primarily through research, and they do, actually, make sense.
According to the American Psychiatric Association (APA), the bereavement exclusion was removed because:
- Both physicians and grief counsellors recognize that bereavement can last between 1-2 years.
- Bereavement is recognized a significant stressor that can precipitate a major depressive episode.
- When major depressive disorder occurs in the context of bereavement, it adds an additional risk for suffering, feelings of worthlessness, suicidal ideation, poorer somatic health, worse interpersonal and work functioning, and an increased risk for persistent complex bereavement disorder (a new possible disorder being researched).
- Bereavement-related major depression is most likely to occur in individuals with past personal and family histories of major depressive episodes. It is genetically influenced and is associated with similar personality characteristics, patterns of comorbidity, and risks of chronicity and/or recurrence as non–bereavement-related major depressive episodes.
- The depressive symptoms associated with bereavement-related depression respond to the same psychosocial and medication treatments as non–bereavement-related depression.
Moreover, there is now more guidance on how to separate normal bereavement from depression. According to the APA:
“Thus, although most people experiencing the loss of a loved one experience bereavement without developing a major depressive episode, evidence does not support the separation of loss of a loved one from other stressors in terms of its likelihood of precipitating a major depressive episode or the relative likelihood that the symptoms will remit spontaneously.”
What’s with all the Negative Feedback? Is the Removal of the Bereavement Exclusion Good?
So although the APA carefully made this decision and freely admits that bereavement is not depression, people have jumped all over them saying it is, “medicalizing and trivializing our expectable and necessary emotional reactions to the loss of a loved one and substituting pills and superficial medical rituals for the deep consolations of family, friends, religion, and the resiliency that comes with time and the acceptance of the limitations of life.”
I don’t agree with that.
What I have said before I will say again, this change is as useful as the doctor applying it. If a physician sees the removal of this exclusion as a reason to diagnose more people with depression, then that’s what will happen; but if a doctor takes a responsible approach and follows the information on the difference between bereavement and depression contained within the DSM-5, then no, the change is not bad.
In fact, one could argue this change is good because it recognizes that bereavement is not a two-month affair. I actually find this recognition validating for all the people out there grieving a loved one.
In the end, I feel like a lot of people knee-jerked to complain about this change without really considering the reasons behind it. I fully appreciate any physician who wants to curb overdiagnosis, but I’m just not sure complaining about this change is the way to do it.