When Should Normal Grief be Considered Major Depressive Disorder?

The DSM 5 removes the bereavement exclusion from the diagnostic criteria for Major Depressive Disorder (MDD). In earlier versions of the DSM, MDD could not be diagnosed within the two months following a loved one’s death. The current guidelines now allow this diagnosis within two weeks of loss, the same amount of time required for the diagnosis of MDD in general. This change has been controversial throughout the mental health community. 

On one side of the issue are those who believe removing the bereavement exclusion is harmful and inappropriate. They argue that grief is not universally defined and is affected by many factors. The way an individual experiences grief depends, in part, on their mental health baseline, levels of attachment with the deceased, and cultural attitudes about death. The age of the deceased and the cause of death also affect the way people conceptualize the grieving process. Therefore, no two cases of grief will look the same.

Critics of this change also contend that while depression and grief may look similar, they are not necessarily the same and require different treatment approaches. They believe allowing the diagnosis of MDD within only two weeks of the grieving process creates pathology around grief and incorrectly labels a natural response to death. Some fear grief will be labeled an abnormal mental state which requires treatment rather than a process of love that needs to be experienced. Along with this, are concerns that people who are grieving normally will be prescribed unneeded anti-depressant medication which will numb their experience rather than allowing them to feel and process their pain. 

Others applaud the removal of the bereavement exclusion as a way to destigmatize mental illness because it helps to normalize the depression many people feel after a loved one’s death. They argue appropriate diagnosis often gives the client something tangible to understand about the way they feel and allows them to find greater levels of support. It allows people to feel ok about feeling bad long after their loss, whereas the bereavement exclusion suggests that they should be returned to normal functioning within two months unless they are mentally ill. Supporters do not think the change makes normal grief pathological but rather allows for clinicians to diagnose MDD for those whose grief experiences warrant it. The DSM is not a set of binding rules, and mental health practitioners now have a greater ability to discern when the MDD diagnosis needs to be given. Due to this, people who need to receive treatment for depression, rather than just grief, can access it sooner. Access for treatment for MDD and grief are especially important because depression, even when related to grief, is linked to higher rates of suicide. 

While I agree that normal grief should not be considered a pathological, overall, I support the removal of the bereavement exclusion. Mental health practitioners need to be able to diagnose and treat MDD along with grief when they determine it is appropriate to do so. In all cases, therapists are expected to use their expert clinical judgment and sensitivity to the client’s needs before attributing any diagnostic labels. Rather than limiting the ability of clinicians to use their best personal judgment when diagnosing depression and grief, the DSM 5 creates far more flexibility. There is no mandate to diagnose MDD following the death of the loved one, but if a practitioner felt it would be beneficial to do so, they are empowered to do so by the updated diagnostic criteria. The bereavement exclusion’s removal gives therapists more flexibility to help clients suffering from grief and MDD without implying that extended grief is abnormal.