Open Journal of Depression
2014. Vol.3, No.1, 9-12
Published Online February 2014 in SciRes (http://www.scirp.org/journal/ojd) http://dx.doi.org/10.4236/ojd.2014.31004
Expanding the Boundaries of Major Depressive Disorder in
DSM-5: The Removal of the Bereavement Exclusion
H. Russell Searight
Department of Psychology, Lake Superior State University, Sault Sainte Marie, USA
Received November 19th, 2013; revised January 3 rd, 2014; accepted January 13th, 2014
Copyright © 2014 H. Russell Searight. This is an open access article distributed under the Creative Commons
Attribution License, which pe rmits unrestricted use, distribu tion, and reproduction in any medium, provided the
original work is properly cited. In accordance of the Creative Commons Attribution License all Copyrights ©
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2014 are guarded by law and by SCIRP as a guardian.
The recent publication of the Fifth Edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM 5; American
Psychiatric Association, 2013) appears to have triggered more
controversy than its predecessors. The DSM 5, the first signifi-
cant revision of this internationally accepted system for psychi-
atric diagnosis in the past 20 years, has been the subject of
much pre- and post -publication criticism and debate—much of
which has occurred in the popular press (Satel, 2013). One of
these controversies centers on the distinction between major de-
pressive disorder (MDD) and bereavement. Technically, “bere-
avement” refers to an individual’s state after losing a loved one
while “grief” describes the individual’s psychological reaction
to the loss. The two terms are often used interchangeably in the
literature—a convention which will be followed herein.
Historically, previous DSM guidelines have included a pro-
viso that clinicians should not diagnose a patient with MDD
when there was evidence that the symptoms occurred immedi-
ately after the death of a loved one. Specifically, while the
symptoms for MDD as well as their duration, have remained
essentially the same in the transition from DSM-IV-TR to
DSM-5, the guidelines for excluding a diagnosis of MDD in the
context of bereavement have been removed in the recent revi-
sion. In the DSM-IV-TR, there was a clear directive at the end
of the list of MDD’s diagnostic criteria to avoid diagnosing
MDD if symptoms were better accounted for by bereavement
(American Psychiatric Association, 2000). In the previous sys-
tem, even if the specific criteria and time duration had been
fulfilled for a major depressive episode (MDE), the diagnosis
was not given if symptoms were temporally associated with the
death of a loved one and were of less than two months’ duration.
The rationale for the exclusion, though not well articulated in
the DSM, has generally been assumed to avoid placing a medi-
cal diagnosis on a normal, albeit emotionally difficult, life tran-
sition. In addition, grief research had indicated that MDE sym-
ptoms and a bereavement-related reaction overlapped conside-
rably (Wakefield, 2011). It was assumed that when associated
with bereavement, depressive symptoms would dissipate in se-
veral months without formal treatment. These assumptions have
been called into question—a factor likely associated with the
recent bereav ement exclusion.
While not specifically stated in the DSM 5, research evi-
dence has accumulated over the past two decades calling the
bereavement exclusion into question. Investigators have found
few differences in symptoms between recently bereaved indivi-
duals and those with MDE (Horwitz & Wakefield, 2007). Ad-
ditionally, there have been a small series of studies indicating
that bereaved individuals may benefit from antidepressant me-
dicati on. Whi le the DSM-5 i ncludes an extended footnote about
how to distinguish MDE from bereavement, the note concludes
with an admonition to clinicians to be aggressive in diagnosing
depression even in the context of a recent loss. Critics of the
DSM-5 have suggested that the decision to drop the bereave-
ment exclusion reflects the medicalization of distress, a grow-
ing norm in Western culture to translate psychosocial distress
into medical symptoms with a pharmacological treatment. These
critics view the removal of the bereavement exclusion as part of
an economically fueled movement to expand the boundaries of
psychopathology to increase the market for pharmacotherapy
(Frances, 2013; Greenberg, 2013). From a broader philosophi-
cal perspective, there are concerns that bereavement-related di-
stress may be meaningful for the survivors and should not be
artificially dimin ished with psychopharmacologic balm (Frances,
2013; Elliott, 2000).
DSM-5 Recommendations for Distinguishing
Grief from MDD
The DSM-5 contains an extended footnote about distingui-
shing grief from MDD. While acknowledging that dysphoria-
may be part of grief, this mood state is seen as much more per-
sistent and constant in MDD compared with bereavement. Gri-
eving individuals are likely to experience more variability in
mood including periods of happiness alternating with intense
sadness triggered by thoughts of the deceased. The course of
grief also differs with sadness becoming less intense in days to
weeks while MDD’s adverse mood states are much more ex-
tended. Worthlessness and diminished self-esteem, while com-
mon in MDD, are generally absent in grief. DSM-5 acknowl-
edges that both MDD and bereavement may be associated with
suicidal ideation; however, the underlying motivation differs. In
MDD, suicidal thoughts are commonly associated with feelings
of worthlessness or as a mechanism to relieve emotional suf-
fering. By contrast, suicidal thinking is less common in bere-
avement and when it occurs is usually associated with a desire
OPEN ACCESS 9
H. R. SEARIGHT
to join the deceased. The DSM-5 authors caution diagnosticians
to be aware of the likelihood of MDD even in the context of in-
While some of these distinguishing criteria seem relatively
clear, the ability to discriminate bereavement’s “feelings of
emptiness and loss” from MDE’s “persistent depressed mood
and …inability to anticipate happiness or pleasure” (American
Psychiatric Association, 2013; p. 161), is likely to demand
more of the clinician’s acumen and time. Given that most pa-
tients with MDD are diagnosed and treated by primary care
physicians (Callahan & Berrios, 2005), it may be difficult to
distinguish these subtleties in a standard 10 - 15 minute office
visit particularly when there are comorbid medical issues.
Bereavement Does Not Differ from Reactions
to Other Life Stressors
The removal of the bereavement exclusion in the DSM-5 has
been attributed to several research findings in the past 20 years.
Historically, the DSM, while not making it a formal diagnosis,
has included discussion of bereavement. For example, DSM-
IV-TR describes the difference between complicated bereave-
ment which triggers an episode of MDD and symptoms asso-
ciated with loss that resolve within two months which are not
formally diagnosed (American Psychiatric Association, 2000).
Wakefield and colleagues completed a series of studies and
concluded that there is little support for the bereavement exclu-
sion. Comparisons of persons fitting DSM IV-TR’s description
of complicated bereavement found little difference in symp-
toms or severity of symptoms from those with uncomplicated
bereavement (Wakefield, Schmitz, First, & Horwitz, 2007). Un-
like MDD which is often chronic, only 10% - 12% of persons
who are bereaved still show symptoms of MDD at one year
following the loss (Wakefield & Horwitz, 2007). It is estimated
that without the bereavement exclusion, approximately 20% -
40% of bereaved individuals would be diagnosed with MDD
(Horwitz & Wakefield, 2007).
Wakefield et al., (2007) provide additional evidence support-
ing the view that the MDD’s diagnostic boundaries should be
contracted rather than expanded. In comparative analyses of
large samples of persons with depressive symptoms, they found
no differences in the actual symptoms or their severity in re-
sponse to death of a loved one versus in response to other loss-
es such as sudden unemploymentor, marital dissolution. Based
upon these findings, Wakefield and colleagues (2007) have
argued that when MDD symptoms are associated with any type
of significant life event, a mood disorder diagnosis should not
be given. Wakefield’s (2011) major criticism of the DSM crite-
ria is that they fail to take into account the symptoms’ context
and the bereavement exclusion should be extended to emotional
reactions to these other life events-thus reducing the prevalence
Conversely, however, these research findings and the ac-
companying reasoning can be used to support the view that
bereaved individuals should receive a diagnosis of MDD. Wa-
kefield and colleagues found that the same complement of de-
pressive symptoms characterizing bereavement were no differ-
ent than symptomatic responses to other life events such as an-
ticipated work lay-off or learning of a romantic partner’s infi-
delity (Horwitz & Wakefield, 2007). Since individuals experi-
encing depressive symptoms associated with other life stressors
would, according to current standards, be diagnosed with MDD
if symptoms were present for two weeks, bereaved individuals
should receive the diagnosis as well. With the removal of the
bereavement exclusion, Horwitz and Wakefield (2007) predict
that one-third to one-half of bereaved individuals will meet cri-
teria for MDD during the first month immediately following the
Pharmacotherapy of Bereavement
Treatment of grief with psychotropic medication has been
studied in small samples—often without the benefit of double
blind placebo controlled designs. Another limitation of this re-
search is that the conditions treated in these studies are some-
what heterogeneous with complicated grief, bereavement-re-
lated MDD and bereavement alone included. Early studies, us-
ing tricyclic antidepressants (TCAs) demonstrated some reduc-
tion in depressive symptoms but a more modest effect for grief
intensity. While the majority of studies are simple prepost inve-
stigations with small sample sizes, Zisook and colleagues (2001)
compared the effects of an 8 week trial bupropion on a group of
patients compared with an intention-to-treat group. Both groups
demonstrated significant improvement in depressive symptoms
with a more modest reduction in grief. In a comparison of psy-
chotherapy with and without medication, Reynolds and col-
leagues (1999) found the most favorable outcome on depressive
symptoms for combined interpersonal psychotherapy and nor-
tiptylene (69%) with nortiptylene alone (56%) demonstrating
superiority over placebo groups. However, neither of these ac-
tive treatment groups demonstrated significant reductions in
Studies involving SSRIs while fewer, suggest that these me-
dications may have greater impact on grief as well as depres-
sion. For example, in an open-label trial of escitalopram, re-
sponse to medication was 83% for depressive symptoms but
only 45% for symptoms of complicated grief (Hensley, Slono-
minski, Uhlenhuth, & Clayton, 2009). A smaller trial of 16
weeks of escitalopram found a 38% reduction in grief intensity
after 16 weeks. Of not e, however, the correspondi ng intention to
treat group demonstrated a 24% reduction in grief (Bui, Nadal-
Vicens, & Simon, 2012; Shear, Fagiolini, Houck, et al., 2006).
In sum, while not an exhaustive review of research in this
area, findings to date suggest that medication for bereavement
may lead to more rapid resolution and/or substantially reduce
depressive symptoms. However, from a quantitative perspective,
pharmacotherapy appears to have less pronounced impact on
the experience of grief.
Is Grief Necessary?
Arguing that bereavement is not a psychiatric disorder,
Frances (2013) and others have noted that grief is a common
behavioral reaction that occurs among non-human mammals.
For example, macaques deprived of group membership exhibit-
ed a stereotypic behavior pattern that differed from those with
normal social contact. Of particular interest was the finding that
these socially deprived macaques exhibited diminished seroto-
nin activity in the prefrontal brain region (Bui, Nadal-Vinces, &
Simmon, 2012; Fontenot, Kaplan, Manuck, Arange, & Mann,
1995). Evolutionary psychologists have generated multiple the-
ories about grief. Outward changes in behavior may elicit sup-
port from others. Archer (1999) suggests that grief is the neces-
sary outgrowth of the evolutionary advantage of social attach-
H. R. SEARIGHT
While noting the commonality of the grief response across
species, Frances (2013) also raises moral and philosophical
objections to dia gnosing gri eving individuals with MDE. Frances
argues that there is something inherently offensive in reducing
grief to a disease: “Medicalizing grief reduces the dignity of the
pain, short-circuits the expected existential processing of the
loss, reduces reliance on the many well-established cultural ri-
tuals for consoling grief, and would subject grievers to unne-
cessary and potentially harmful medication” (Frances, 2013: p.
187). Medicalizing grief both impugns the integrity and “dig-
nity” of the survivors’ emotional experience, but also is disres-
pectful to the life that was lost (Frances, 2013). Grief and be-
reavement rituals are long-standing responses that have impor-
tant meaning in their specific culture. In some cultures such as
Japan, intense contemplation and melancholia have been seen
as signs of morally superior character (Kitanaka, 2012). MDE,
as a disorder is only beginning to be recognized in Japan (Kita-
Treating Grief: Harm or Enhancemen t
The implicit corollary of converting grief to MDD is that
within American medicine, diagnoses are inextricably tied to
available treatment. However, if bereavement can be treated
with pharmacotherapy, should it be?
Before further discussion of the moral side of this issue, it is
worthwhile to consider the impact of implicitly diagnosing and
overtly treating everyone exposed to a stressful live event.
Critical Incident Stress Debriefing (CISD), typically adminis-
tered as a group intervention, to persons exposed to life-threa-
tening traumatic events such as first responders, continues to be
commonly used, and often mandated. However, data from mul-
tiple studies suggest that the iatrogenic affects often outweigh
any benefit from CISD (Lohr, Hooke, Gist, & Tolin, 2004).
While there are likely multiple explanations for this finding, it
is likely that many first responders have a working coping style,
often including some element of avoidance, that is successful.
By forcing these individuals to repeatedly relive the trauma and
face the accompanying emotional turmoil, successful adapta-
tion may be prevented. Research on CISD suggests that pro-
viding psychological treatment to all who experience a trau-
matic event may actually harm those receiving it. Wakefield
(2011) notes that similar to PTSD, the meaning of bereave-
ment’s depressive symptoms depend on the context in which
they occur. Re-defining bereaved individuals as ill subject them
to unwanted treatment that may challenge pre-existing coping
However, if a medication can reduce symptoms and improve
functioning, should everyone losing a loved one be required to
simply “muddle through” (Horwitz & Wakefield, 2007: p. 23)
life’s inherent complications when there is a relatively conve-
nient pharmacological alternative? Aside from the possible side
effects of antidepressants and the finding that 30% - 40% of
patients prescribed these medications fail to improve, is there
potential harm from labeling all recently bereaved individuals
as psychiatric patients? As a clinician, the author remembers
the days before SSRIs when tricyclic antidepressants (TCAs)
were commonly prescribed. While SSRI’s are not free of side
effects, they are not usually as disruptive as the pronounced
sedation, and anticholinergic effects during the first 7 - 10 day s
of taking a TCA. The question remains—if there are few ad-
verse medication effects and the patient appreciates the possi-
bility of being a non-responder, is there any reason not to be
treated for bereavement?
If grief is seen as having little value and as an unfortunate
life event that temporarily impairs functioning, the availability
of pharmacotherapy to aid in coping should be welcome. Simi-
lar to cognitive enhancement with drugs such as Modafanil
which extend concentration, antidepressant medication can re-
duce some of the distress accompanying bereavement. Critics
of psychiatric enhancement are often described as espousing
“pharmacological Calvinism” (Klerman, 1972), a view that dif-
ficulties in cognitive-emotional functioning are meaningful,
character-building burdens to be shouldered rather than atte-
nuated with psychotropic medication. Calvinism in particular,
is relevant when it comes to bereavement. Medication may
“cheapen” the experience of grief by making it less intense and
disruptive to one’s life. In some cultures, an individual demon-
strating little sadness after the loss of a parent or spouse would
be considered deviant because of the absence of extended
mourning. Contemporary mental health Calvinists, argue that it
is immoral to feel “good” after the loss of a loved one. Indeed,
even in industrialized countries such as the US, there is concern
that getting back to “normal “ too soon is a form of denial and
will be associated with a high level of unresolved grief or de-
layed emotional upheaval.
This essay has reviewed the clinical, empirical, and philoso-
phical issues raised by both proponents and opponents of the
DSM-5 bereavement exclusion. Whether widespread clinical
application of DSM-5’s bereavement exclusion will increase
the incidence of MDE diagnoses remains to be seen. In addition,
how readily patients will seek and accept pharmacotherapy to
address the grief of interpersonal loss is also an open question.
The “ground work” for pharmacotherapy of bereavement has
been laid with the use of SSRIs to “buff up” one’s personality
(Kramer, 1993), and drugs such as modafanil to improve cogni-
tive functioning a nd eliminate fatigue associ ated with shift work.
However, bereavement, with its often specific cultural and reli-
gious context, does not appear comparable to these other uses
of enhancement therapy. The ethical issues surrou nding “ar tifici al”
coping with loss through the medicalization of bereavement are
likely to continue to be debated.
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