Some psychiatrists, however, lambasted the proposed revisions as far too complex and burdensome, arguing that no clinician would ever use the new system. The work group continually revised the proposal, simplifying it as much as possible, and won approval from the DSM-5 Task Force. But the APA Board of Trustees ultimately voted against the proposed changes, according to Andrew Skodol of the University of Arizona College of Medicine, a member of the Personality Disorders Work Group. As a result, the DSM-5 chapter on personality disorders is more or less the same as the DSM-IV chapter. Skodol is not sure why the Board of Trustees rejected the proposal at the 11th hour, but "there was a lot of behind-the-scenes lobbying to keep things the way they were," he says. The work group's proposal has been relegated to a back section of the manual to "encourage further study."
Recognizing that grief can quickly precipitate depression
Symptoms of depression—such as low mood and energy, insomnia, feelings of worthlessness, loss of pleasure and change in weight—must persist for at least two weeks to meet the DSM-IV criteria for a major depressive episode. The DSM-IV stipulates, however, that someone who has recently lost a loved one should not receive a diagnosis of depression unless the relevant symptoms last longer than two months. The idea is that, in these cases, what looks like major depression is probably bereavement—more commonly known as grief—a typical and transient response to loss that does not require medication. The DSM-5 has eliminated this "bereavement exclusion" and replaced it with a few footnotes describing the differences between grief and depression. Now, someone can be diagnosed with depression, and ask their insurance company to cover the costs of antidepressants, as well as talk therapy or other treatment, in the first two months following the death of a loved one.
Richard Friedman of Weill Cornell Medical College and others have criticized this decision, worrying that it will encourage overdiagnosis and overmedication. According to the APA, however, the change reflects the new understanding that bereavement is a severe stressor that can precipitate a major depressive episode relatively quickly.
Some studies have shown, for instance, that symptoms of depression co-occurring with bereavement are similar to depression unrelated to bereavement in their severity and duration, response to antidepressants and long-term outcomes. Therefore, the reasoning goes, people who are grieving and clinically depressed within two months of a loss should have access to treatment. Similarly, some researchers have questioned why, when it comes to identifying depression, the DSM makes an exception of grief following the death of a loved one, but not of any other kinds of loss or psychosocial stress such as divorce, unemployment, financial failure or romantic rejection. The International Classification of Diseases, published by the World Health Organization, makes no such exceptions.
In an article published in Depression and Anxiety in May 2012, Sidney Zisook of the University of California, San Diego, and his co-authors examined the results of several review papers and studies and concluded that the available evidence supports the removal of the bereavement exclusion from DSM-5. "Acknowledging that bereavement can be a severe stressor that may trigger an MDE [major depressive episode] in a vulnerable person does NOT medicalize or pathologize grief!" they wrote (emphasis theirs). "Rather, it prevents MDE from being overlooked or ignored and facilitates the possibility of appropriate treatment. Furthermore, removing the BE [bereavement exclusion] does not imply that grief should end in two months. Indeed, for many individuals, grief lasts for months, years or even a lifetime in its various manifestations, whether or not it is accompanied by MDE."