Is Grief a Mental Disorder? No, But it May Become One!
The Fallacy of Misplaced Empathy Continued…
Some people are inclined to say, “Hey, I’d be depressed, too, if I found out I had cancer! He should be depressed!” And this is exactly the wrong response! Of course, these well-meaning individuals are trying to be empathic, trying to put themselves in their friend’s shoes. And they are right, to this extent: almost anybody receiving a diagnosis of cancer (even a highly-treatable form, such as prostate cancer) would be knocked for a loop. Anybody would feel sad, anxious, confused, and distressed, for a time. They might very well lose sleep and not feel like eating. But not everybody would develop a full-blown, suicidal depression. In fact, most people with cancer adjust to their situation, and do not develop a major depressive episode.
These same well-meaning individuals often counsel against psychotherapy or medication for somebody like Pete. They reason as follows: “Anybody would be depressed, in Pete’s shoes. He doesn’t need medication! He has to go through this and deal with it naturally. Grief is just part of life. Sometimes, you just gotta suck it up!” Curiously, when a patient comes out of abdominal surgery, experiences severe post-operative pain, and requests some morphine, nobody says, “Hey, forget it, buddy! I’d be in pain, too, if I just had abdominal surgery!” Many people don’t realize that psychotherapy, medication, or both together can literally be life-saving for those with severe depression.
Rather than being fixated on what is “normal” — or on what you or I would feel in Pete’s situation — it is more important to recognize that Pete is not experiencing a “productive grief.” Rather, he has many of the hallmarks of a full-blown major depression. To get a better sense of this severe type of depression, consider this passage from author William Styron, in his memoir, Darkness Visible:
“Death was now a daily presence, blowing over me in cold gusts. Mysteriously and in ways that are totally remote from normal experience, the gray drizzle of horror induced by depression takes on the quality of physical pain….[the] despair, owing to some evil trick played upon the sick brain by the inhabiting psyche, comes to resemble the diabolical discomfort of being imprisoned in a fiercely overheated room. And because no breeze stirs this caldron, because there is no escape from the smothering confinement, it is entirely natural that the victim begins to think ceaselessly of oblivion… In depression the faith in deliverance, in ultimate restoration, is absent…”
There are, of course, no “bright lines” that demarcate normal grief; complicated or “corrosive” grief; and major depression. And, as I argued in my New York Times piece, a recent loss does not “immunize” the grieving person against developing a major depression. Sometimes, it may be in the patient’s best interest if the physician initially “over-calls” the problem, hypothesizing that someone like Jim or Pete is entering the early stages of a major depression, rather than experiencing “productive grief.” This at least allows the person to receive professional help. The clinician can always revise the diagnosis and “pull back” on treatment, if the patient begins to recover rapidly.
To be sure, antidepressants are sometimes prescribed too readily, particularly in a hectic, primary care setting where the doctor has fifteen minutes to assess the patient. And, unfortunately, psychotherapy is getting harder and harder to come by, in this age of tightly-managed (and shockingly under-funded) mental health care. But in cases where major depressive symptoms are present — even if they appear to be “explained” by a recent loss — some form of professional treatment is usually necessary. Remember, you can’t pick yourself up by your bootstraps if you don’t have boots!
Ronald Pies, MD teaches psychiatry at SUNY Upstate Medical University and Tufts University School of Medicine. He receives no monies, research support, or stipends from any pharmaceutical companies, and is not a major stockholder in such companies. He is Editor-in-Chief of Psychiatric Times, a monthly print journal that does accept advertising from pharmaceutical companies.
The views expressed here do not necessarily represent those of SUNY Upstate Medical Center, Tufts University, or Psychiatric Times.
Further Reading & References:
Pies, R. The Anatomy of Sorrow: A Spiritual, Phenomenological, and Neurological Perspective. Philosophy & Ethics in Medicine.
Pies, R. Redefining Depression as Mere Sadness. New York Times, Sept. 15, 2008.
Horwitz AV, Wakefield JC: The Loss of Sadness. Oxford, Oxford University Press, 2007.
Simon NM, Shear KM, Thompson EH et al: The prevalence and correlates of psychiatric comorbidity in individuals with complicated grief. Compr Psychiatry. 2007 Sep-Oct;48(5):395-9. Epub 2007 Jul 5
Kendler KS, Myers J, Zisook S. Does Bereavement-Related Major Depression Differ From Major Depression Associated With Other Stressful Life Events? Am J Psychiatry. 2008; Aug 15. [Epub ahead of print] PMID: 18708488
Kessing LV: Endogenous, reactive and neurotic depression—diagnostic stability and long-term outcome. Psychopathology 2004;37:124-30.
Depression. Mayo Foundation for Medical Education and Research.
Pies, R. Everything Has Two Handles: The Stoic’s Guide to the Art of Living. Hamilton Books, 2008.
Pies, R. (2009). Is Grief a Mental Disorder? No, But it May Become One!. Psych Central. Retrieved on August 27, 2015, from http://psychcentral.com/blog/archives/2008/10/04/is-grief-a-mental-disorder-no-but-it-may-become-one/