Social Work Advance Access published June 10, 2013
COMMENTARY

The DSM-5 and the Bereavement Exclusion:
A Call for Critical Evaluation
Kara Thieleman and Joanne Cacciatore

T

he discipline of social work has long
prided itself on taking a holistic view of
human suffering and well-being and for
advocating for conditions that enhance the quality
of life for vulnerable populations. Yet, as others
have pointed out (Carney, 2012), social workers
have remained mostly silent when it comes to the
changes proposed for the next edition of the
Diagnostic and Statistical Manual of Mental Disorders
(DSM-5). This is perplexing, given the debate
this revision process has sparked in the mental
health professions. In addition, social workers
provide a substantial portion of mental health services in the United States, typically using the DSM
(Frazer, Westhuis, Daley, & Phillips, 2009), and
any changes to the manual will likely have farreaching effects on the individuals social workers
serve and on the profession as a whole.
For this reason, the DSM-5 changes require critical evaluation from social work. Though a wide
range of changes has been proposed, we wish to
consider just one aspect that has generated heated
debate and public outcry: a change to the criteria
for major depressive disorder (MDD). Whereas
DSM-IV offers a bereavement exclusion that
discourages the use of this diagnosis within a
two-month postdeath period, DSM-5 proposes to
eliminate this exclusion and allow a diagnosis of
MDD two weeks after a death. We consider this
proposal in light of its potential effect on bereaved
parents, who constitute an especially vulnerable population socially, emotionally, and even economically
(Song, Floyd, Mailick Seltzer, Greenberg, & Hong,
2010), due to the traumatic nature of infant and child
death.
Although bereavement is widely recognized as a
unique life event, the effects of loss must be considered within the context of individual experiences
such as the relationship to the deceased and the

doi: 10.1093/sw/swt021

© 2013 National Association of Social Workers

circumstances surrounding the death. Among bereaved parents there are many variables that affect
the intensity and duration of grief, such as the
degree and quality of attachment (Kreicbergs, Valdimarsdottir, Onelov, Henter, & Steineck, 2004),
manner of death (Arnold, Gemma, & Cushman,
2005), religious affiliation (Wijngaards-de Meij
et al., 2005), ethnicity (Laurie & Neimeyer, 2008),
prior history of mental disorder (Hensley, 2006),
concordant partner responses (Dyregrov & Dyregrov, 1999), and perceived level of social support
(Cacciatore, Schnebly, & Froen, 2009; Mann,
McKeown, Bacon, Vesselinov, & Bush, 2008).
The current edition of the DSM fails to take many
of these factors into consideration, and instead
relies on an arbitrary two-month cutoff point
before symptoms of grief contribute toward a diagnosis of MDD. However, it is well accepted that
grief often lasts well beyond two months (Shuchter
& Zisook, 1993), even under the best of circumstances, and that there is a significant overlap with
depressive symptoms. Symptoms common to both
states include sleep disturbances, fatigue, anhedonia,
changes in appetite, and enduring emotional distress. These effects may be especially pronounced in
bereaved parents, and feelings of worthlessness or
shame and suicidal ideation, also considered symptoms of depression, are not uncommon in this population (DeFrain, 1986; Murphy, Tapper, Johnson,
& Lohan, 2003; Qin & Mortensen, 2003).
Because of their intense reactions, bereaved parents are at high risk of having their understandable
suffering misinterpreted as signs of a mental disorder if the bereavement exclusion is eliminated.
The change to DSM-5 would allow a diagnosis
of MDD as early as two weeks following the death
of a child. This move reflects a wider trend of
narrowing the bereavement exclusion over time, as the
DSM-III allowed up to one year for the bereavement

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exclusion. This was subsequently shortened to
two months in DSM-IV. However, overall, DSMIII-R criteria have been shown to yield a lower
rate of false positives and to do a better job of distinguishing complicated from uncomplicated
bereavement than does DSM-IV (Wakefield,
Schmitz, & Baer, 2011). Removing the bereavement exclusion entirely may result in an even
higher rate of false positives (Wakefield et al.,
2011) as well as subsume what have been shown
to be normal responses to loss under the MDD
category.
An increase in false positives would translate
into more individuals being given a diagnosis of
MDD inappropriately, which could lead to misguided treatment. It is likely that many bereaved
individuals would receive psychotropic medication, as it is the most frequent, and increasingly the
sole, mode of treatment offered for various mental
disorders (Mojtabai & Olfson, 2008; Olfson &
Marcus, 2010), despite a growing body of research
questioning the efficacy and safety of this approach
(see Andrews, Thomson, Amstadter, & Neale,
2012). It is important to note that there is no sound
empirical data supporting the effectiveness of such
medications for grief (Hensley, 2006). Yet preliminary research suggests that bereaved parents are too
often prescribed psychiatric medications shortly
after the death of a child, sometimes even the same
day, before criteria for most mental disorders could
possibly have been met (Cacciatore & Thieleman,
2012). The DSM-5, in making it easier to diagnose
MDD immediately following a loss, may legitimize
this alarming trend even though this practice is not
evidence based.
One of the arguments for removing the
bereavement exclusion in DSM-5 is that the features and course of depression are the same, no
matter what kind of event may have triggered an
episode (Zisook et al., 2012). However, studies
have yielded disparate results, with some suggesting
that depressive symptoms following bereavement
may be different from other forms of depression
(see Gilman et al., 2012). These postulations are
confounded by the fact that most studies on which
the latter assumptions are made are based on conjugal grief research, and findings may not apply to
all bereavement experiences. For example, there is
very little research conducted with bereaved parents on this topic. The evidence suggests that this
particular population may be different from other

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bereaved groups, and this may be the case with
other specific groups as well.
For most people, no other loss is as painful and
agonizing as the death of a child. Reactions to such
a loss are typically intense, with evidence that
symptoms of grief persist for a year or longer
(Dyregrov & Matthiesen, 1991). In one study, 41
percent of parents, none of whom had a history of
any mental disorder, showed significant levels of
grief-related separation distress an average of 4.5
years following the death of their child (McCarthy
et al., 2010). Another study found that it took
about nine years following the death of a child for
loss-related symptoms to fully abate (Kreicbergs
et al., 2004). Regardless of symptom levels, it is not
unusual for grief following the death of a child to
last a lifetime and to change in intensity over time.
In one study (Arnold et al., 2005), 63.5 percent of
parents reported that their grief continued an average of 24 years following the death of a child.
There were no differences in overall life satisfaction
between these parents and those who felt their
grieving process had ended. For the majority of the
bereaved parents, intense grief does not indicate
pathology; instead, continued grieving, even when
it includes intense reactions, represents a way to
maintain a connection to the deceased child
(Arnold et al., 2005).
These findings highlight the importance of recognizing what is normal within a population,
rather than on a comparison with the general population. Given the traumatic nature of the death of
a child and the documented parental responses, it
appears unreasonable to expect that grief-related
symptoms will resolve within two weeks or two
months. To rely on either one of these arbitrary
cut-off points for diagnosing disorder, without
consideration of the context, risks pathologizing
normal human emotion and challenges what it
means to be human and to love deeply. As social
workers know, context does matter, and studies
have documented that mental health professionals
do consider context when assigning diagnoses
(Kim, Paulus, Nguyen, & Gonzalez, 2012). The
DSM criteria for depression do not appear to be
adequate for distinguishing normal responses from
psychopathology in bereaved parents.
There are many other criticisms of the MDD
criteria, including that this category encompasses
minor depressions that are likely to be time limited
even if untreated (Pies, 2012) and that the criteria

Social Work

focus on traits more common in women, potentially leading to gender bias (Hartung & Widiger,
1998). Certainly, the existing criteria are far from
perfect. However, removal of the bereavement
exclusion only compounds these problems. For
instance, women tend to report higher levels of
distress and to be more emotionally expressive following a loss, areas that are typically the focus of
grief measures (Dyregrov & Dyregrov, 1999), so
more bereaved mothers than fathers are likely to
qualify for the MDD diagnosis under DSM-5.
We believe that some grieving individuals do
need treatment. Of course, sensitive and compassionate support and professional help should be
available to anyone who needs and desires it.
However, mental health professionals should be
cautious of assigning a label of a mental disorder
simply to allow someone to obtain insurance reimbursement for such help. There are legitimate
forms of suffering that are not caused by a mental
disorder, of which the normal, though intense and
enduring, distress experienced by bereaved parents
is but one example. If changes are to be made
to the MDD diagnosis, perhaps retaining an
expanded bereavement exclusion that recognizes
the long-lasting effects of loss is the most appropriate move.
Overall, there has been little empirical justification for the changes proposed for DSM-5. Like
many of the proposals for DSM-5, the revision of
the MDD criteria lacks the empirical evidence
and thorough field testing to evaluate its utility
and possible effects. For the population of bereaved
parents, this move appears highly problematic and
risks pathologizing normal human reactions. The
DSM-5 process has also been widely criticized for
lack of transparency and ability to self-correct, and
in the past there have been concerns that special
interests such as ties between drug companies and
DSM committee members may have been driving
the process more than rigorous science (Cosgrove,
Krimsky, Vijayaraghavan, & Schneider, 2006).
The lack of transparency in DSM-5 makes many of
the proposed revisions even more problematic.
We have covered just one aspect of proposed
changes to DSM-5. There are many other proposed revisions that may be problematic and
require careful consideration and active debate.
Social workers, with their unique strengths perspective and recognition of the variety of factors
that influence behavior and well-being, have

Thieleman and Cacciatore/The Bereavement Exclusion

valuable input in these matters. Yet social workers
have remained strangely silent when it comes to
the DSM. We encourage social workers to critically
evaluate all of the proposed changes in light of how
they might affect the populations social work is
committed to serving and in terms of potential conflicts with the stated values of NASW.
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Kara Thieleman, MSW, is a doctoral student, and Joanne
Cacciatore, PhD, is assistant professor, School of Social
Work, Arizona State University, 411 N Central Avenue,
822K, Phoenix, AZ 85004; e-mail: karajt@gmail.com.
Original manuscript received May 5, 2012
Accepted May 30, 2012

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