Grief, Major Depression, and the Bereavement Exclusion: DSM-5’s View

The removal of the so-called “bereavement exclusion” from DSM-5 was one of the most contentious decisions the DSM-5 work groups made, and many clinicians continue to find the distinction between ordinary grief and major depression confusing. However, said Ronald W. Pies, M.D., at APA’s 2014 annual meeting, grief and depression are actually distinct constructs, despite some overlapping features. Pies, a professor of psychiatry at SUNY Upstate Medical University and Tufts University, noted that major depressive syndromes occurring shortly after the death of a loved one (bereavement) do not differ substantially in symptoms, course, impairment, outcome, or treatment response from major depression in any other context or occur “out of the blue.” Pies stated that removing the bereavement exclusion was justified by the best available (albeit limited) studies and did not amount to “medicalizing grief,” as some have argued.

Disqualifying a patient from a diagnosis of major depression simply because the clinical picture emerges after the death of a loved one risks closing the door on potentially life-saving interventions, Pies said. The “exclusion” principle also fails to recognize that MDD is often a highly overdetermined process, involving multiple, interacting causes; for example, someone who develops a major depressive syndrome shortly after a loved one’s death may also be depressed owing to concomitant hypothyroidism and recent job loss. It’s often impossible to tease out which factors are “causal.” Furthermore, the DSM-IV’s provisions for overriding the bereavement exclusion were potentially misleading, Pies said. For example, DSM-IV would not have applied the exclusion to overtly suicidal patients. But Pies noted that not all depressed patients will acknowledge being suicidal, and the risk of suicide is not conferred solely by the presence of suicidal ideation; rather, overall severity of depression and hopelessness also elevate risk of eventual suicide.

Pies noted that if the clinician believes the patient’s clinical picture reflects normal, bereavement-related grief, the “V Code” of “Uncomplicated Bereavement” (V62.82) may be used. A period of “watchful waiting”—beyond the two-week minimum required for a diagnosis of major depressive disorder—is sometimes warranted in ambiguous cases of post-bereavement depression. And, not all bereaved patients judged to have a major depressive episode will require antidepressant treatment. Pies noted that mild-to-moderate cases may respond to psychotherapy alone.