iStock_000001234220SmallOne of the more controversial changes in DSM5, the removal of the grief exclusion is sometimes cited as evidence of the increasing ‘medicalization’ of normal human behavior. That’s a reasonable concern, of course. But the grief exclusion was always a fragile concept and it shouldn’t come as a big surprise that DSM5 got around to eliminating it.

First, what is it?

For several decades the diagnostic criteria for major depression had specifically excluded persons with a recent bereavement (death of a loved one). The rationale was that grief represented a normal reaction to loss and wasn’t pathological. Psychiatrists were encouraged to hold off on a diagnosis of depressive disorder until several months after such a loss.

There were objections to this from the outset. First, major depression presents quite differently from the sadness associated with grief. A competent diagnostician could be expected to differentiate between the two without an enforced waiting period. Besides, the depression that accompanies bereavement isn’t very different from that which can accompany many forms of severe stress — trauma, for instance. Should those be subject to a waiting period, too?

Lastly, a psychiatrist would ordinarily conduct a full diagnostic assessment, so why not leave it up to the clinician to determine whether treatment or medication was required? Other factors in the case might be more important than bereavement.

Anyway, we’ll have to wait and see how it all turns out. If there’s a dramatic change in the number of persons diagnosed with depression, for instance — that would be something to pay attention to.


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