Imagine this scenario. Your seven-year old son is riding his bike, and takes a nasty fall. He has a gash on his knee that looks pretty bad, but you get out your first-aid kit, clean the wound, put a little iodine on it, and cover it with a sterile gauze pad.
Two days later, your son complains that his knee hurts a lot and that he “feels crummy.” He didn’t sleep well the night before, and his face seems a little flushed. You remove the gauze pad and notice that his knee is red and swollen, and there is a foul-looking, greenish liquid oozing out of the wound. You get that sinking, “Uh-oh!” feeling, and decide you had better have your family doctor take a look at the knee.
As you are about to drive off, your friendly neighbor buttonholes you and asks where you are going. You explain the whole situation to him. He looks at you like you are from Mars, and says, “Are you nuts? You want this kid to grow up to be a wimp? He is supposed to be in pain! Pain is a normal part of life! We all have to learn how to live with pain. Redness and swelling are normal, after you bang up your knee! Let the kid heal up naturally! The doctor is just going to put him on some damn antibiotic, and you know the kind of side effects those drugs have. Those doctors, you know, they just make money on all those prescriptions!”
Would you feel that your well-intentioned neighbor was giving you good advice? I very much doubt it. Well, it’s the kind of advice some well-meaning but misinformed individuals give, when dealing with the issue of severe grief and depression. In part, this attitude is a remnant of our Puritan roots—the idea that suffering is God’s will, that it ennobles the soul, or that it is just plain good for us!
Now, it is certainly true that life is full of bumps, bruises, and falls. It is also full of disappointment, sorrow, and loss. Not all of these are occasions for a medical diagnosis or professional treatment — most are not. But there are times when a simple cut can become infected, and there are also times when so-called “normal” grief can become a very nasty beast called clinical depression. Learning how to deal with disappointment and loss is part of becoming a mature human being. Coping with loss may indeed be a “growth-promoting” experience, under the right circumstances. But “hanging tough” and refusing to seek help in the face of overwhelming pain — physical or emotional — is an affront to our humanity. It is also potentially dangerous.
The Case of Jim
I recently had an essay published in the New York Times (9/16/08), in which I argued that the line between profound grief and clinical depression is sometimes very faint. I also argued against a popular thesis that says, in effect, “If we can identify a very recent loss that explains the person’s depressive symptoms — even if they are very severe — it’s not really depression. It’s just normal sadness.”
In my essay, I presented a hypothetical patient — let’s call him Jim — who was based on many patients I’ve seen in my psychiatric practice. Jim comes to me complaining of “feeling down” for the past three weeks. A month ago, his fiancée left him for another man, and Jim feels that “There’s no point in going on” with life. He has not been sleeping well, his appetite is poor and he has lost interest in nearly all of his usual activities.
I deliberately withheld a lot of important information that any well-trained psychiatrist, psychologist, or psychiatric social worker would obtain. For example: in the past three weeks, had Jim lost a great deal of weight? Was he awakening regularly in the wee hours of the morning? Was he unable to concentrate? Was he extremely slowed down in his thinking and movement (so-called “psychomotor retardation”). Did he lack energy? Did he see himself as a worthless person? Did he feel completely hopeless? Was he filled with guilt or self-loathing? Had he been unable to go to work or function well at home, over the past three weeks? Did he have any actual plans to end his life?
I wanted to make the case ambiguous enough to be suggestive of clinical depression without “clinching” the diagnosis by providing answers to all these questions. (A “yes” answer to most of these questions would point to a serious bout of major depression).
But even given the limited information in my scenario, I concluded that people like Jim were probably better understood as “clinically depressed” than as “normally sad.” I argued that individuals with Jim’s history merited professional treatment. I even had the temerity to suggest that some grieving or bereaved individuals who also show features of a major depression may benefit from antidepressant medication, citing the research of Dr. Sidney Zisook. (If I had to write the piece all over again, I would have added, “Brief, supportive psychotherapy alone may do the job for many people with Jim’s symptoms”).
Well, my goodness! The blogosphere lit up like a swarm of fireflies. You would think that I had advocated the killing of the first-born! I should not have been surprised by the reaction from the “Hate Psychiatry First” crowd, who get their information about psychiatry from Tom Cruise. They wrote me off as either a shill for the drug companies [see disclosure], or someone who was “declaring grief to be a disease.” One of the most irate bloggers opined that my medical license should be revoked!
Nearly all of my colleagues were very supportive and felt that I had made some good points. But a few responses from mental health professionals really surprised me. One PhD-level “bereavement specialist” scolded me for failing to let my hypothetical patient “heal naturally” from his “normal grief”. Never mind that my patient had lost interest in nearly all his usual activities, and sounded vaguely suicidal—to this critic, feeling suicidal was all par for the course and nothing to get too upset about. She spoke of her ten years of experience, and how many people with “normal grief” feel like “not going on” with life. Well, after 26 years of practice, I guess I just lack confidence!
One thing I do know: nobody inside or outside my profession is very good at predicting who will attempt suicide. There is also good research from Dr. Lars V. Kessing showing that suicide rates are not markedly different for those whose depression is apparently a “reaction” to some stressor or loss, versus those with no apparent cause for their depression. And, as I note in my NY Times article, it is not always clear whether a depressed person is “reacting” to some life event, or whether the depression preceded and precipitated the event. For example, the person who insists, “I got depressed after I lost my job” may actually have been depressed while still employed, and may not have been working at her usual efficiency.
A Different Way of Naming Grief
Let me be clear: most people who experience a major loss or setback do not develop a major depressive episode. Even most people who have lost a loved one are more likely to experience “normal” grief—I’ll have more to say on “normal” in a moment—than to develop clinical depression. Most will recover with simple support, kindness, and empathy from friends and family. Uncomplicated grief is not a disease, nor does it require medical or professional treatment.
But a certain percentage of the bereaved do not travel this benign path of “natural healing.” Many years ago, Freud described a kind of pathological mourning in which the grieving person experiences profound guilt and self-reproach—sometimes irrationally blaming himself or herself for the death of the loved one. Recently, Dr. Naomi Simon and her colleagues have described a syndrome that closely resembles pathological mourning, termed Complicated Grief (CG). This condition follows the loss of a loved one, lasts at least six months, and consists of:
- A sense of disbelief regarding the death
- Persistent, intense longing, yearning, and preoccupation with the deceased
- Recurrent intrusive images of the dying person; and
- Avoidance of painful reminders of the death.
CG is chronic, debilitating, and associated with the development of medical problems, reduced ability to work, and suicidal tendencies. Yet most patients with CG don’t meet the full criteria for a major depressive episode. So—is CG “normal” or “abnormal”?
I often think the term “normal” creates more problems than it solves. If 99 out of every 100 stockbrokers jump off the George Washington Bridge when the market tanks, is their behavior “normal”? Does normal mean “average”? Does it mean “healthy”? Does it mean “one standard deviation from the mean”? When it comes to describing grief, I prefer the terms “Productive Grief” and “Non-productive Grief.” You can also think of these as “Healing Grief” versus “Corrosive Grief”, respectively.
If you have ever lost a loved one, or experienced some other major loss — let’s say, having an important relationship break-up — you may have been fortunate enough to experience “Productive Grief.” Family and friends may have gathered around you, giving you love and support. You felt sad, of course, lost sleep, ate poorly, and probably wept off and on for days, or even weeks. But you appreciated the support of others. And, with time — maybe 4 or 5 weeks, maybe several months — you were able to reflect back on all the good times and good memories, surrounding the lost loved one. You were able to place the person’s death in the larger context of your own journey through life, and actually take quiet pleasure in looking back at old photos and letters that reminded you of the one you lost. In effect, you were able to grow as a person, even as you grieved your loss.
In contrast, the person who experiences Non-productive or Corrosive Grief experiences a kind of shrinkage of the self. He or she feels not only deep sorrow, but also a pervasive sense of being “eaten up” by their grief. Try as they might, friends and loved ones do the person no good: their efforts at comfort and support are rebuffed, or are experienced as intrusive. The person with Non-productive grief usually prefers to be alone, and resents attempts to bring her out of her shell of self-involvement. Often, these unfortunate souls feel worthless, guilty, or “not worth keeping around.” Many of these individuals would probably meet Dr. Simon’s criteria for Complicated Grief—and some will develop a full-blown episode of major depression.
The Fallacy of Misplaced Empathy
Many people who are experiencing intense and distressing forms of grief or bereavement are reluctant to seek professional help. To make matters worse, some well-meaning friends and family do not believe the grieving person should seek help. Why? I already alluded to one reason in my opening vignette: we are heirs to the Puritan tradition, with its emphasis on enduring suffering, and “picking yourself up by your bootstraps.” There is a time for this sort of robust, self-reliant philosophy: namely, when you have “boots”. The severely depressed person feels not only “bootless”, but legless. He or she usually lacks the energy and motivation to get up and get on with life.
I believe there is another reason why friends and family are sometimes slow to see that their loved one is clinically depressed. I call it “The fallacy of misplaced empathy.” This usually takes the form of the statement, “You’d be depressed, too, if…” or “You should be depressed if…” Let’s say that Pete, a good friend of yours, receives a diagnosis of prostate cancer. Three weeks later, Pete has stopped eating, stopped visiting friends, given up his favorite hobbies, and says to his wife, “There is no point in going on. I’m a goner!” He is awakening at three a.m. every morning, and has lost 10 lbs. since his diagnosis. He does nothing all day but sit staring at the TV. He refuses to shave or bathe. What is the proper response on the part of friends and family?
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.
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Links to This Article
Gardening with PTSD (10/5/2008)
Teen Mental Health Blog » Blog Archive » Depression is not just being Blue (11/17/2008)
Teen Mental Health Blog » Blog Archive » Depression is not just being Blue (11/17/2008)
From Psych Central's World of Psychology:
Do Antidepressants Dull Your Emotions? An Interview with Ron Pies, M.D. | World of Psychology (5/21/2009)
31 Comments to
“Is Grief a Mental Disorder? No, But it May Become One!”
I loved this article. I struggled with complicated grief. In 1994 my husband and I adopted a little boy. When he was almost 6 months old and the adoption final in 2 weeks his birth mother changed her mind and took him back. The depression I experienced was massive. Most people thought that I should just “give it to God” after all I was a Christian and God would walk with me through this grief. I was hurting too much to allow God to help me and became VERY suicidal and did act on it several times. I was finally hospitalized, put on medications, and given much needed therapy (as my marriage also did not survive this loss). Yes we do have to feel the pain of grief and work through the process, but there are medications to help us get to the point that we can face our issues.
What I have observed many times, and often say to people, is that it is impossible to understand an emotional state that you cannot experience. The well-meaning folks in your article, who try to exhibit empathy, automatically relate the depressed person’s symptoms to their own experience of being “down.” In reality, they cannot relate to his experience, because the severity of serious depression if far outside the scope of their experience.
I would like to thank Christy for relating her painful experience with complicated grief. I am very glad, Christy, that you were able to get appropriate professional help when you needed it–this is a great example for others! And, of course, for those who develop a major depressive episode after such a tragic loss, the best treatment approach often combines psychotherapy with medication.
I also want to thank Dr. Thompson for his well-taken point. I have noticed that, among many members of the general public and the media, the word “depression” means something like “feeling blah” or “kinda down in the dumps.” This, of course, is not what mental health professionals mean when we describe clinical depression! The quote in my article, from William Styron, illustrates how different “the blahs” or “the blues” are from severe depression. The Mayo Clinic website I referenced also has good descriptions of what clinical depression feels like.
For those who are interested in some of the spiritual and existential aspects of grief and depression, I hope you will take a look at my article in PEHM, which is also referenced in my article for PsychCentral. –Best regards, Ron Pies MD
Thank you Dr. Pies for this wonderful article. Personally, I can relate to the scenarios you describe as I experienced complicated grief as a result of several significant losses in rapid succession. I quickly realized that my symptoms were not part of a “normal grief reaction” as I had experienced that in the past. Your article describes this difference nicely. On a professional level, I plan to use your article in my teaching of allied health students to facilitate their comprehension of unproductive grief and improve their ability to identify individuals in their care who may need more support than is typically offered for persons experiencing grief.
I empathize with Dr. Pies whose attempt to help people recognize “non-productive grief” results in opposition by those subscribing to the “Puritan tradition of enduring suffering.”
The past seven years I’ve developed prevention-focused emotional health education program. My focus is on understanding brain responses to everyday “emotional wounds”. It has been a major challenge trying to introduce brain-based coping skills development to 4th-6th graders in classrooms. On one hand most schools don’t consider this “life skill” relevant to elementary school objectives. What is most remarkable, however, is opposition from school mental health professionals! I’ve heard “You just can’t mention ‘hurt feelings’ in a classroom and then just leave.”
So I decided that after 7-yrs. encountering the “We don’t talk about this” rule in most schools regarding teaching kids coping skills, I decided to create a free and open-access website that can serve as a world-wide “virtual classroom” available 24/7 to pre-teens, their parents and teachers. In the first 7-months, this site has been accessed by 9,000 people from 98 countries!
In the past seven years I reached just 700 students with just a 3-hr. classroom demonstration of basic coping brain function literacy. Even in that ridiculously limited period of 3-hrs., most students reported significant gains in emotional resilience and self-acceptance. Immediately after the project they reported greater ease in recovering from everyday emotionally wounding experiences. However, those most adamantly opposed to teaching pre-teens brain-based coping skills in the classroom to get over stressful experiences are “clinically trained” professionals. Some say they fear that just mentioning brain functions underlying our self-perception of “hurt feelings” and feeling “bad” when we experience them is a “taboo” subject. The implication is that 9-12 yr. olds can’t handle it. So now we don’t need gatekeepers to prevent pre-teens from becoming more coping competent, since they and those who care for them can learn about these issues by simply going Online.
Many thanks to Dr. Scaffa and Ronald Brill for their comments. I’m delighted, Dr. Scaffa, that you will make use of the article in your teaching. And, Mr. Brill, I can appreciate your frustration with some mental health professionals working in school settings who are suspicious of your efforts. I personally do not treat youngsters, but I do believe that teaching pre-teens cognitive and behavioral coping skills makes a good deal of sense!–Best, Ron Pies MD
Portage North Middle School in Portage, Michigan has implemented a structured program that is designed to address the issues of relationships between students and how student’s behavior effect other students as well as teachers. This program came out of a recogniton there were problems students were having that were interfering with their education. They are talking about much more than ‘problem’ students.
The school board took the bold step of appointing someone to work fulltime with the students and the teachers to implement the program. The person working in this program has direct contact with teachers on a daily basis as well as being available for students who have problems they need to deal with.
The entire school staff is being trained to create an environment for students and teachers that will create the behaviors and relationships that will insure better teaching and learning.
Thank you for this article, I have been researching complicated grief for a few weeks now as I have a client who recently came to me who has been crying for three years and is unable to stop. For the past eight years, she has been prescribed anti-depressants, anti-convulsives, Valium,and a huge variety of sleeping and sedative medications and has also had ECT treatment, none of which has worked, she is still crying.
She was sent to us as a last resort and hopefully we’ll be able to help her, but her grief is so enormous, whether she will ever get over it is difficult to imagine. She saw her father beat her mother to death! Can you ever get over something like that when it’s in your head, no matter how hard you pretend it’s not there?
Grief is a cancer, it eats away at your heart and soul and sometimes won’t just go away,no matter how much empathy or love, or medication we give a person.
My husband committed suicide in 1978, 20 years later my son is still grieving for him, he doesn’t say it but I can see it in his eyes. Depression is the outcome of a prolonged and immovable emotional pain.
Grief is taken far too lightly and as you say, dismissed too easily, and on top of a previous inclination towards depression, can push many people over the edge.
In the past month in Australia two handsome and seemingly happy young men, one a fabulous singer and one a great young actor threw themselves out of buildings to end their pain. What a waste of life. And apparently no-one close to them was aware of it.
Just last week put a page about grief and loss on our web-site, so it is interesting that you also have taken up this cry to help try to stop the endless pain of grief.
Thank you again
Dr Pies, what a fantastic article! You write with such clarity and argue your points so effectively. I am not medically trained but it seems to me that everything you stated was common sense, yet common sense unfortunately is a trait lacking for so many, even amongst your peers as you point out when referencing some of the initial responses to your earlier article. I hope this article has led to some of those detractors reconsidering their position on this important issue.
I note with interest your comment about over prescription of medication in the primary care setting due to the limited timeframes doctors have with their patients. It seems it is just too easy for a doctor to prescribe something and get on with seeing their next patient. This is something my company is seeking to address through an application that enables doctors to spend more quality face to face time with their patients so that they can better diagnose their patient and arrive at more appropriate treatment programs (which may of course include medication).
Thank you again for a very insightful article.
All the best.
My thanks to both Annie Moyes and Marshall Couper. Ms. Moyes, I agree with your comments on what I would call “corrosive grief”–especially when severe psychic trauma is involved, since then PTSD may complicate treatment and delay response. (Therapies aimed at the PTSD component could be useful in such cases).
Mr. Couper, I very much appreciate your kind words, and hope that–if you see fit–you will circulate my article to those who might benefit from it. As for your company, I wish them the best! Many people don’t realize that the vast majority of antidepressant prescriptions are written not by psychiatrists, but by “PCPs”, family practitioners, etc. I have the utmost respect for these colleagues, who are often the first to admit that they lack the time–and often, the training–to make sophisticated decisions about prescribing these medications.
Thanks for your thoughtful article. I was grateful to come across the Grief Recovery Handbook when I needed it most, and we now recommend and sell many copies through our charity. It offers a structured and constructive way to work through major bereavements and I think should be available “on prescrption” in every primary care doctor’s office as a first line treatment. Bereavements are often associated with trauma which can result in PTSD, and I was grateful to be offered swift and effective treatment in one session of Human Givens Rewind Therapy. Again, this needs to be much more widely available. Maybe the article is to some extent tending towards a false dichotomy between normal grief and depression needing medication. Good antidepressant talking therapy along Human Givens lines that focuses on getting your life working again (rather than getting stuck in a downward spiral of painful and highly arousing feelings) is likely to be helpful for anyone struggling with overwhelming loss.
(www.hgi.org.uk http://www.grief.net)
I thought the first example, with the boy who hurt his knee, was not a good example to use with the neighbourly advice[?] given.
At no point in the example are there behaviours or cognitions mentioned to indicate a state of severe grief and depression.
Dad thought about taking his son & his gashed knee, to a doctor (to be on the safe side; there was swelling, the area was red).
I agree that indications are not always salient, that the line is faint. But feel I am drawing a long bow to consider my neighbour possibly in grief &/or depressed, if no indicators are present at all (that I know of at this point in my life/practice).
Why not consider the possibility of child abuse?
Or peer bullying?
As with Jim~ really! I want to read that article and comments!!!
With the emphasis on happiness being equal to romantic relationships, break-ups are no different from any grieving process/cycle
Many personal relationships take on so much meaning making in our lives, at the neglect of creativeness and discovery that change (life!) overwhelms and instigates feelings of loss and alonenessness.
Medicine, in all its forms, has been prescribed by people for healing, maintenance and growth. Medicine is part of Culture; it is the committed study of its application and affects that must be monitored.
Thank you, Dr. Pies, for information I truly needed. My beloved teen son died of cancer just over 2 1/2 years ago. Although I didn’t yet have the terms “corrosive grief” or “complicated grief” I was worrying because after having begun to feel better in the third year took a turn for the worse recently and just got so low. Complicated in the non-clinical sense…a relationship breakup and my remaining son (younger) struggling with Oxycontin addiction. But I don’t fit the four bullets. I’m just tired. Tired of dealing. Really didn’t get any rest after several years of dealing with cancer and death before having to cope with my grieving son’s issues.
Don’t think I can pull up by my bootstraps! But need to get going with a grief group and seek out info as I did tonight.
There is so much awful on the internet; yet so much that is valuable and empowering. Thanks for the session!
By the way….what is with the awakening in the wee hours?????? I’ve thought it was just conditioned after such an intense stretch of night sweat chores, but I should be over that and it recurs sometimes for a month at a time.
Hi, Kimberly–Many thanks for your heartfelt and generous note. I doubt many of us can imagine the kind of grief–or is “griefs” the word?–you have borne these past few years. I wish I had some healing words of consolation, but I am sure you have heard them all–both helpful and not-so- helpful. If, however, you are now feeling very “tired”, or “tired of dealing” with life, I would certainly encourage you to seek out some professional help. As for early morning awakening–I wouldn’t presume to say what that means in your case, but it is a very common sign in major depression. However, because a variety of medical problems can cause insomnia, I would encourage you to get a thorough medical evaluation, if you have not already had one recently. And, I wish you continued courage, hope, and healing.—R. Pies MD
I enjoyed reading your article.
I’m currently going through what would qualify according to your criteria as major depression.
I hadn’t really experienced death first hand until recently. I’d been to some funerals for friends’ loved ones, but never someone in my immediate family. Then one terrible Saturday morning, a dog of ours died suddenly from heart failure. The images are still jagged and fresh in my mind even though it’s been four months since it happened. Frantic drive to the vet, arriving too late, burying our dog in the back yard while my wife, who considered this dog the best, most wonderful dog she’d ever known, wept mournfully.
I feel so responsible, yet on an intellectual level I know that it wasn’t in my power to save him. Emotionally though I’m still torturing myself over it, and I’m really finding it difficult to hang in there.
I’ve promised my wife I wouldn’t take my own life, but every day I think about it, in part because life seems now so much more cruel than it did before this all happened. I guess when death got “personal”, it put me on a sort of precipice, where I now stand every day. My wife, our remaining dogs, wondering what the future holds, one or more of these compel me to step away from the precipice and return to life.
I think spirituality on some level factors into thoughts of suicide. Will there be an afterlife? Or will suicide be a simple “off switch” to selfishly end one’s own suffering?
I’m very fortunate to have my wife whom I very dearly love and who loves me likewise, and our three other dogs (one a recent addition to the pack, who needed us as much as we needed her, as it turns out, but longish story there).
I’m feeling nowadays a bit like the captain of some doomed ship, deciding whether to lash himself to the mainmast and go down with it, but I hope to find some way to put the grief in perspective and move on and upward.
I will reread your article and try to take your suggestions to heart.
Hi, Alan–First, I’m very sorry to hear of the death of your beloved dog under such traumatic circumstances. It does seem clear from your account that the expected grieving and mourning process has not gone well for you, and that you are tormented by feelings of guilt that have not yet been worked through. The fact that you think regularly of not going on with your life is a further indication that you have a serious mood disorder. The good news is, there are many effective treatments for depression, and this includes both “talk therapy” and medication. You
don’t mention whether or not you are seeing a mental health professional at this point, and I assume you are not–but I would strongly recommend this course of action. You could get the ball rolling by discussing the situation with your family or general physician, who should be able to provide initial treatment and/or refer you to a specialist. I imagine you may be reluctant to do so for a variety of reasons, as many people are–but this is really the best way to feel better and get on with your life. I hope you will seriously consider this right away, and I wish you the very best. –Sincerely,
Ronald Pies MD
Hi -
Years ago, I had an excellent experience (no meds) with a psychiatrist who believed in using talk therapy and no meds with teens. It took longer, perhaps, than adding meds to the mix but I was not having depression as a primary issue. I needed to understand myself better - as well as my parents, family dynamics, etc.
My grief is based on the fact that nearly EVERY psychiatrist I see today practically throws meds at me. Where is the combo of a good psychiatrist and talk therapist that I knew? Where can people find good counsel these days? Is there hope that the pendulum will swing back and insurance companies won’t call the shots, when (clearly, to me, at least) the person doing the medicating should also be observing and being the therapist as well.
Amen to the above comment. Also, I just want to reiterate that while Dr Pies is not calling for anyone with grief to seek out intensive treatment, I hope he realizes that the status quo these days is for patients to show up at their PCP/internist /obgyn and complain of grief issues and get offered pills, sometimes literally in the next sentence by the provider. Soooo, watch out for what you advocate, because, as I was guilty of this at a more recent posting with Dr Pies, people might misinterpret the message and think you are selling pills for ills that need reassurance and support. That is why I have the alias therapyfirst, to keep that in mind for those who interact with me.
Have a nice holiday weekend.
Thanks to JPeers and my colleague, therapyfirst, for their comments. I fully agree that psychiatrists are under enormous pressure to pull out that Rx pad and “write a script”–but the very best ones still resist this pressure, and do indeed provide well-integrated treatment, often including both psychotherapy and (when necessary) medication. For more on my concerns about the practice of psychiatry, please see my blog on the Psychiatric Times website, under “The Couch in Crisis”
http://www.psychiatrictimes.blogspot.com/
Related posts are also found on Therese Borchard’s website, Beyond Blue
http://blog.beliefnet.com/beyondblue/2009/05/when-does-grief-turn-into-depr.html
Best regards, Ron Pies MD
Loss and grief is a big topic. In the abstract grief seems manageable but when it is personal: loss of a beloved person, marriage, job, pet or even hope, it becomes much more complicated.
The brain is an organ and it can wear out or down just as any other body part can. Some medication, when needed, can make an enormous difference. It can help the swimmer’s stroke (speaking metaphorically) be stronger in a rough and turbulent sea.
Thank you for quoting William Styron, too, Dr. Pies. I loved that book because it was so bare bones honest. Deep love - when lost to death - will cause deep grief and it can quickly become a major depression. Thank you, too, for your thoughtful article to get people thinking, talking, and considering how to recognize clinical depression.
Mary Jane Hurley Brant, M.S., CGP
Author of When Every Day Matters:
A Mother’s Memoir on Love, Loss and Life
Simple Abundance Press, Oct. 1, 2008
Many thanks for your wise observations, Ms. Brant. It is very gratifying to see a clear appreciation of the complexities and nuances involved in severe, prolonged grief and its treatment. –Best regards, Ron Pies MD
In 1980 I lost my fiancee to a horrific automobile accident. The day after the accident I turned 20. Every year since I cannot help but remember everything on my birthday. Family and friends surrounded me with support etc. I continued to grieve. I drank heavily. I had too much sex. But I continued to go to work in our local hospital as a pharmacy techician. I can recall numerous times being drunk and going to work. My boss let it slide, as he had his own demons to fight. I knew things were not right and I continued down the slippery slope of depression even though I didn’t know what it was. All I knew was that I cried all the time and was so sad. I kept everything bottled up and and kept going. I told no one about how I was feeling. My family was tired of hearing it and the friends that I had tried to cheer me up by buying me more booze. I was so desperate that I attempted suicide with pills that I brought with me from work. Luckily a friend stopped by soon after I took them. She was a nurse and had ipecac in a kit in her car. After she made me vomit I begged her not to tell anyone. She never did. But I continued to suffer and continued to slide down the very slippery road of depression. I was so young and hurting so much I did not know what was wrong with me. I had many painful relationships and did all the wrong things to ease the pain. I went to college during those years and graduated on the dean’s list despite my frequent and deepening depression. When I was done with school I got married to the husband of my nightmares. Things went very well for the first couple of years. Then things changed. After a while he stopped having relations with me and as a matter of fact after 11 years of marriage I got the message I dreaded to hear. He preferred the opposite sex. I was devastated and angry. I was working in a mental health clinic at the time and the nurses working there had previously noted that I had a real problem. They took me under their wings and finally after all of 12-13 years I got the help that I needed. Back to my marriage…when I got divorced I had 7 years of therapy and medications under my proverbial belt. However, it threw me into a deep pit of darkness all over again. To add fuel to this fire he said that he never loved me. I had my 4th hospitalization. New med changes, thoughts of suicide again rose to the surface. I’ve been hospitalized 3 more times over the ensuing years. I am now remarried. My meds are working and I am reasonably happy. I can certainly remember feeling all the things the Dr. has written in this article. I very strongly agree that grief can become a debilitating and horrible journey of severe depression. I am now diagnosed as Bipolar II with anxiety. Is it any wonder? I’m sorry that I have rambled on so long, but if anyone is helped by my experience I am gratified.
Many thanks for your brave and illuminating story, Ms. Richardson. Your narrative certainly brings home the point I was striving to make in my article: loss does not “immunize” us from depression, and an understandable grief reaction can sometimes evolve into a severe and debilitating depression. Often, the depressed person tries to “self-medicate” with alcohol or other substances, as your story makes clear. I am glad that you finally got the help you needed, and I hope that your life’s journey will bring you healing and happiness. –Best regards,
Ronald Pies MD
Dr. Pies, this is a great article. I must confess that this time, unlike almost all the time, I did not read all the comments as I was sort of impatient to comment myself, and to remember what I wanted to say.
Just two quick thoughts.
First, I was thinking about the so called ‘normal grief’ that goes with losing a ‘loved one’. I have lost two ‘loved ones’, and it was very manageable because in both cases, we had a chance to say ‘good bye’, and more importantly, both sides knew that we loved each other. So, the ‘loved’ actually made it much easier. On the other hand, sometimes grief is much harder when you hated the one who died, especially if this is a parent, or someone close. So, my point about the ‘loved one’…well, I already said so.
The other regard the comment from Kevin Thompson, PhD, and I agree with his comment a lot. (and I am taking it a step further) People who have not gone through an experience really don’t know how they will feel if this happens to them. The most important thing otherwise is to really listen to a person and not assume that you know everything better. (Because, You DON’T) There is so much other involved then the tragic ‘thing’ we are assuming is everything. (And since i was also carefully listening to your talking about Jim, I would have done exactly the same thing, and I think you did the right thing)
Whenever I comment, I usually talk about my own experience and for the purpose of giving a real example. (And I should add that I have had so many experiences in my life, from the best to the worst, and that I value all of them the same)
Two years ago I was diagnosed with a severe and deadly, very rare type of breast cancer, that required chemotherapy, surgery and radiation and hormonal treatment. Even then, there is an extremely high possibility of recurrence.
I should add, that something horrible had happened to me a few years earlier, an ongoing trauma, that felt like being in combat for years and that I was totally alone with. It was the worst thing that ever happened to me. I could easily deal with the abusers, as those abusers really could not hurt me so badly. All they could do it kill me. The worst was the betrayal of the so called ‘good people’, and who hang out their shingles with ‘we are here to help’. I never received any help and understanding, and it was so terrible and outside of normal what happened, i had no words for it, plus I was suffering from severe PTSD.
So, when I was diagnosed with this cancer, everyone felt sorry for me. Like my neighbor, she told me if she ever was diagnosed with this she would kill herself as she was not as strong as I was. She also told me she would commit suicide if something happened to her son. I didn’t say anything, but the truth is that she has no clue what she would actually do in that case.
To make a story short, I was not the least bit depressed or even grieving about this cancer. And the medical staff and everyone was so wonderful, in contrast to the other, this was more good than having cancer was bad. also, I felt that now I finally could use the treatment of mutilation, burning, and poisoning to get out ‘the other’ and it really helped. (I am talking about meaning, and which is not the same as being psychotic)
Anyway, this was a healing life changing experience and that is the end. Katrin (unedited)
PS: When you are diagnosed with cancer, it usually is not nearly as bad as you think it is, and before you had it, and what you thought it would be like.
The thing is, that there is just nothing you can do about it, so you just deal with it,
Katrin,
Many thanks for sharing your extraordinary journey through trauma and grief–and for reminding us that grief differs for each of us, depending on a multitude of psychological and personal factors. Also, thanks for providing such a wonderful example of getting on with life! —R. Pies MD
Another thought, and after having done, (read) a lot of research, and listened to so may with this on Breast cancer Forums, etc.
It doesn’t matter if someone is diagnosed with stage 1 bc (breast cancer), and which is like 98% curable, or another with stage 3, or 4, and which is much more serious, and/or incurable.
The grief, or the response, or level of depression, etc, is the same for all groups.
I thought that was quite interesting.
Last I want to say something that I think fits with this article and discussion, and with trauma and grief, and all that.
What I really appreciated about having cancer was(is), that it doesn’t hurt your soul.
For me, injury to the soul is the worst of all injuries and pains, and I think of Depression often as being really ’soul sick’. You either cannot, or are not allowed to, or otherwise are prevented from telling about your own truth.
This is all for now. Thanks again, Dr. Pies, for listening, as I know you are.
PS: And even with therapy, that does not guarantee that one can talk about one’s own truth, and for various reasons, of which one is that the therapist may feel like he is the expert, and the one who knows, and decides what is bad and what is not.
It is also horrible, when a therapist doesn’t allow a patient to change his/her mind, as when one cannot change one’s mind, what possibly else can one change? It is NOT ALWAYS denial!
Now, Dr. Pies may not be one who does a lot of therapy, like ‘therapyfirst’, but he listens, and hears, and that matters the most.
I am fully aware how harmful medications can be. My son was made bipolar for almost seven years from LUVOX, and we spent one whole year trying just about every mood stabler there is to treat the manic depression that was artificially induced, but neither or the psychiatrist was aware off and who did not do this on purpose. If it weren’t for me, my son would be dead, so serious were some of the side effects that usually developed when the medicine began to work, like around day 10. The, one day..it’s a long story, but my son go into trouble and someone called DHS on him. It turned out the case worker was great and he really listened to me, and he asked for my consent to speak to the psychiatrist, and who in turn ordered me to stop the Luvox without any further explanation. This was the very end of my son’s life with bipolar illness and that was 3 years ago, and when he was 17. he is still recovering developmentally from all those years. Those years were so horrible, and I lived in constant fear that my son would kill me and his brother, and that was real.
BUT, therapy and therapists have the same potential to do harm, and serious harm, and this is never talked about. I wonder how many patients have committed suicide because of their therapy. And the higher the training of the therapist, the greater the risk.
Meaning, one of the idiots we were referred to for my son was not so damaging, because it was so obvious that he was ‘an idiot’, offering to pay my son for good behavior. (well, considering the $120 I paid him for his therapy, I am sure he could afford it)
But with psychiatrists, etc, who do therapy, this is not always so obvious when they do harm, especially since the patient by then is so dependent on them, they cannot leave any longer. And more often than one thinks, the ending is horrible, and where the long term therapist actually ends up kicking out the patient and blaming him/her for everything that went wrong.
etc…
Does this mean I hate all psychiatrists and therapists? No, i don’t, but…I am aware.
German: “Da sind Sohne, und Solche”
There are such, and there are such! (except in the german version, such and such are differentiated to mean different such and such.) Like, there are ‘psychiatrists’ and then there are other ‘psychiatrists’ (having a real name already says a lot)
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Last reviewed: By John M. Grohol, Psy.D. on 5 Oct 2009
