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PHILADELPHIA -- Psychiatrists writing new diagnostic criteria for major depression hope an explanatory note will mollify critics of a proposal to let patients grieving a dead loved one receive a formal diagnosis.

Controversy has erupted over whether to drop the so-called bereavement exclusion from the definition of a major depressive episode (MDE) in the American Psychiatric Association's influential guide, the Diagnostic and Statistical Manual of Mental Disorders.

The fourth (and current) edition, DSM-IV, says that patients with grief-related depressive symptoms should not be diagnosed with an MDE within 2 months of a severe loss.

Although an MDE is not itself a codeable disorder, patients must qualify for one to be formally diagnosed with major depressive disorder.

The APA work group developing revised criteria for mood disorders in the forthcoming fifth edition, DSM-5, had proposed to drop the bereavement exclusion entirely, prompting a firestorm of criticism that the effect would be to "medicalize" and/or stigmatize millions of people experiencing normal, and temporary, grief.

Just before the APA's annual meeting began here, the panel unveiled a note to be included in DSM-5. It reads as follows:

"The normal and expected response to an event involving significant loss (e.g, bereavement, financial ruin, natural disaster), including feelings of intense sadness, rumination about the loss, insomnia, poor appetite and weight loss, may resemble a depressive episode. The presence of symptoms such as feelings of worthlessness, suicidal ideas (as distinct from wanting to join a deceased loved one), psychomotor retardation, and severe impairment of overall function suggest the presence of a Major Depressive Episode in addition to the normal response to a significant loss."

At a symposium here dedicated to DSM-5 updates, work group chairman Jan Fawcett, MD, of the University of New Mexico, said the wording is not final. "We're still working on hammering this out," he said.

But the group intends to give the note unusual prominence in the final version.

Normally, such explanations go in the text portion of the DSM-5 book, he said. The work group is proposing to place it directly in the checklist criteria that are what most clinicians use in routine practice, especially in primary care.

The phrasing brings the language closer to that in DSM-IV, in which an MDE could be diagnosed less than 2 months after a loved one's death if grief-related depressive symptoms "are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation."

But since the note is advisory in nature, not part of the checklist proper, clinicians would be free to diagnose an MDE, and therefore major depressive disorder, whenever they believe a patient would benefit from treatment.

Fawcett said the work group still believes that excluding recent bereavement as a trigger for major depression is not scientifically justified.

For example, he said, several studies have indicated that rates of "chronicity and recurrence" of bereavement-related depression do not differ significantly from those seen with other forms of depressive episodes.

Reiterating previous statements from members of his work group, he also said the panel was concerned that the bereavement exclusion could block patients "at risk for the most serious consequences of MDE" -- such as suicide -- from receiving treatment.

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