DSM-5 and the elimination of the major depression bereavement exclusion

As the American Psychiatric Asso­ ciation approved the final version of DSM­5, the Chair of the DSM­IV Task Force Allen Frances declared it to be the ‘saddest moment’ in his career, saying that the final version included ‘changes that seem clearly unsafe and scientifically unsound’. He went on in a blog (Frances, 2012) to list the 10 most potentially harmful changes, amongst which was the deci­ sion to eliminate the grief exclusion criterion from the definition of major depression in DSM­IV, arguing that the loss of the criterion is likely to lead to ‘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’. As a proposal, this was so controversial that it pre­ cipitated a statement justifying this decision from Kenneth Kendler, published on the DSM­5 website (Kendler, 2012). What was a proposal is now an approved change, the implica­ tions of which we will have to deal with until the next DSM edition. To examine the impact of this change it is first useful to consider the exact criterion that has been removed. This is as follows: ‘The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation’. Kendler argues that there are many problems with the criterion and that the best solution was to remove it. To consider the implications of abandoning the criterion, the follow­ ing questions have to be asked. First, has evidence accumulated that the cri­ terion was useful and valid? Second, did clinicians understand and use the concept as it was designed? Third, was it useful in research settings? Fourth, are there administrative con­ sequences of abandoning the exclu­ sion, such as implications for insurance or private health care schemes?