DSM-Depression versus Bereavement

Another controversy erupted last month over a proposed revision to one of our field’s most important tomes, the Diagnostic and Statistical Manual (DSM). This time the debate swirls around bereavement and depression.

In the current DSM-IV-TR, the criteria for Major Depressive Episode include an exclusion for bereavement. A client, in other words, is not experiencing a depressive episode if his symptoms are better accounted for by loss-related bereavement (DSM-IV-TR, p. 356). Bereavement is listed as a separate V-code (V62.82). The assumption is that depression-like symptoms are sometimes normal after a significant loss and therefore not a disorder.

In the proposed fifth revision (DSM-5), slated for publication in May 2013, the bereavement exclusion is eliminated from Major Depressive Episode, as is the V-code for bereavement.

In other words, even if a client’s depressive symptoms are related to a recent loss, the clinician may still diagnose the individual as suffering from a major depressive episode.

But a new article authored by Jerome Wakefield and Michael First of NYU analyzes available studies and challenges the validity of removing the bereavement exception (BE). After examining the studies cited in support of removing the BE and subsequent literature, the authors concluded:

[T]he claimed evidence for the BE’s invalidity does not exist. The evidence in fact supports the BE’s validity and its retention in DSM-5 to prevent false positive diagnoses. We suggest some improvements to increase validity and mitigate risk of false negatives.

The debate, as covered in outlets such as The New York Times and The Daily Beast raises fundamental questions about our field’s stance on “normal” versus “disordered” emotional behavior. Given that depression is often treated with medication, altering the diagnostic criteria for depression can be especially impactful for clinicians and patients alike.

Visit the DSM website for more information about the manual, the proposed changes, and the process for offering input.

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