Australian & New Zealand Journal of Psychiatry 47(4) 391–394 © The Royal Australian and New Zealand College of Psychiatrists 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com Australian & New Zealand Journal of Psychiatry, 47(4) DSM-5 and the elimination of the major depression bereavement exclusion Richard Porter, Roger Mulder and Cameron Lacey DSM Digest As the American Psychiatric Asso- ciation approved the final version of DSM-5, the Chair of the DSM-IV 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 DSM-IV, 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 DSM-5 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? Research evidence Five studies examining aspects of the DSM-IV bereavement exclusion crite- rion have been frequently cited. Kendler et al. (2008) examined the characteris- tics of bereavement-related depression compared with those of depression related to other life events and reported no difference. Kendler argues, on the basis of this and other evidence, that the specificity of the exclusion to ‘bereavement’ is illogical (www.dsm5. org). Corruble et al. (2009, 2011a, 2011b) examined a large number of patients with symptoms of depression and compared those who had been given a diagnosis of DSM-IV major depression and those with depressive symptoms who had been excluded on the basis of the bereavement criterion. Physicians in this study were specifically not trained in the exact use of the cri- terion in order to examine its naturalis- tic use in clinical practice. It could be argued that this gives a critical insight into how clinicians use the bereave- ment caveat. Compared with the included group, the excluded group were similar on most measures includ- ing symptoms, response to treatment and cognitive function. However, an important feature of the study was that in a predominantly general practice set- ting, the baseline Montgomery–Asberg Depression Rating Scale score was around 30, a level of symptomatology which is surprisingly high and may imply that patients were self-selected based on severe symptomatology. The same could be said of the Kessing et al. (2010) study in which more than 60% of the patients were inpatients. Only the investigation by Karam et al. (2009) studied a community sample and DSM-IV bereavement-excluded patients. Characteristics were similar between those with depression and bereavement-excluded patients, but with the caveat that there were rela- tively few of the latter. In sum, there is little evidence of a difference between bereavement and other life events and their effects on mood, and little to sug- gest that there are systematic Commentaries Department of Psychological Medicine, University of Otago, Christchurch, New Zealand Corresponding author: Richard Porter, Department of Psychological Medicine, University of Otago, Christchurch, PO Box 4345, Christchurch 8140, New Zealand. Email: richard.porter@otago.ac.nz DOI: 10.1177/0004867413481504 481504ANP 47 4 10.1177/0004867413481504ANZJP CorrespondenceANZJP Correspondence 2013 Commentaries