It’s been heating up now for the past few weeks as a charge led mainly by professionals. And it has caught the eye of the mainstream media. I’m talking about the revision process for the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5), the reference manual mental health professionals and researchers use to treat patients and design reliable research studies examining mental illness.
The latest upset? The fact that the new DSM-5 suggests that depression could co-occur with grief. Critics see the changes as suggesting the DSM is trying to “medicalize” normal grieving. Anyone who experiences grief after a tragic or significant loss will now be at risk for receiving — heaven forbid — mental health treatment and a diagnosis.
We’ve covered this ground here on more than one occasion, but it appears time to talk about whether depression can occur at the same time as grief or not. My first reaction was — grief is grief, depression is depression, and the two never really co-occur. But a few years ago, I read a piece here on World of Psychology by Dr. Ron Pies which completely changed my perspective.
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Many thanks, John, for the thoughtful reflections on this controversial issue, and for generously referencing my earlier work! I’d like to add just a few comments, as nearly everything I believe about this issue is found in the “Two Worlds” article you cited.
First, it’s very unfortunate that the NY Times article carried the headline, “Grief Could Join List of Disorders.” I don’t blame Ben Carey–a careful writer–since it’s usually an editor that comes up with the headline. In truth, nobody in the mood disorders field (including the DSM-5 folks) wants to claim that “grief” by itself is a “disorder”!
As you indicate, the debate is what to do when a “grieving” patient comes in within 2 months of a loved one’s death, and meets the full DSM criteria for a major depressive episode. Should the diagnosis of major depression be denied or “excluded” simply because the person has experienced a recent death of a friend or family member? Sid Zisook and I, along with many others, say “no”.
Put in colloquial terms, “If it looks like a duck, walks like a duck, and quacks like a duck, there’s a high probability it is a duck, until proved otherwise.” That is to say, just because a person is grieving for a loss does not mean they don’t (also) have a major depression. As you suggest, grief and depression may co-exist; and sometimes, a severe depressive episode can actually interfere with the normal and adaptive process of grieving or mourning.
My earlier piece that you reference (Is Grief a Mental Disorder? No, but it may become one) actually had a somewhat misleading title (my bad!). It implied that grief may somehow “morph” into depression, a bit like those cartoon characters that suddenly transform from one creature into another! That is not the current understanding of grief and depression. A person who grieves a loss may indeed develop a major depressive episode–but not because their grief has “morphed” into another “creature.” Usually, they are still grieving–but now, they have the equivalent of a cold, wet blanket wrapped around their grief, interfering with the “grief work” they need to do, and which usually occurs unencumbered by major depression. (Alternatively, they may have developed what some call “complicated grief” or “pathological grief” in which the grief has come to dominate the person’s entire emotional life, almost like an “addiction”).
Sid Zisook and I would agree with you that we should be very, very careful in assessing a person’s “depression” in the immediate aftermath of a major loss–whether of a loved one, a beloved pet, or a beloved job. We feel that the DSM-IV’s two-week duration criterion for major depression (likely to be carried over in the DSM-5) is usually too little time to know what the person has, or will develop. We usually prefer to wait 3-4 weeks after a major loss, before applying the diagnosis of a major depressive disorder. (There are exceptions: e.g., if the person has strong suicidal intentions, or meets DSM criteria for melancholia). Often, in my experience, a person who is simply in a state of grief will show considerable improvement between weeks 2 and 4, whereas the person with an incipient major depression is about the same or worse. That said, grief is not “over” after week 2 or week 4, and may continue (with or without a co-existing major depression) for months or even years. Nobody has any business specifying a “cut off” for ordinary grief that is not complicated by serious, incapacitating depression!
It’s also important that we not mix up the argument for proper diagnosis with the issue of treatment. Sure: there is a risk that dropping the bereavement exclusion will encourage some harried doctors to prescribe antidepressants when they aren’t needed or appropriate. (Antidepressants are prescribed mainly by non-psychiatric MDs–sometimes after only a very brief evaluation). But this is a problem to be addressed by better education of doctors, and by ensuring greater access to specialists in mood disorder treatment. Basically, whether a depressed person has lost a loved one or not, antidepressants should be reserved for moderate-to-severe major depression that has not responded to “talk therapy.” Medication should rarely be the treatment of first recourse (exceptions: psychotic depression; or severe melancholic major depression with a high suicide risk). The point is this: we should not jigger our diagnostic criteria in order to address a problem of medical education; i.e., doctors need better training on when and when not to prescribe medication.
Finally, thanks for citing my recent piece on “scrapping” the DSM system. We really need a more in-depth understanding of grief and depression, beyond the symptom check-lists of the DSMs. We need to appreciate how the inner world of grief differs from that of depression, so that we can indeed recognize the “proper sorrows of the soul.”
Thanks again, John, for covering this topic!
Best regards,
Ron Pies MD
I wanted to say that I googled why not to kill yourself and of all the answers I read, the page I found which was linked to this page made the most sense and was the least patronising of the pages I read. I wanted to add some comments with respect to that page but I would have had to give an email address and this is a private matter. So I have posted here. What I would add is that I believe it is quite possible that any one googling that question and arriving at that webpage may not be sober. And I think it is important to acknowledge that. People who are in so much pain that they are seeking answers from the web have likely tried to dull it with substances. So it might be worth mentioning that the decision to end your life is ultimately your decision, but it is a decision that is so important that it is one to be made when you are sober. What I appreciated about your website is the fact that unlike every other one, there is no patent assumption that there is someone who cares about you personally. For some people, this is not the case. For those people, that is likely the reason they are in so much pain. Hopefully for me this is only at this particular point in time. But it has been a few years now and when I am not sober I do struggle with staying alive. And then I also wonder if all the other websites are right in that it is worth staying alive because someone else cares that you do, so if no-one cares then what is the point.
According to me, depression is grieving anyway.
Sometimes about something we don’t even realize counsciously. It’s a grieving process that got stuck.
So I agree that the limit is difficult to find…
Here we go again. I guess another example of “hear the lie enough…”
Good Grief!! The backwards thinking, the pure rejection of what the world of psychology determined over 100 year ago is dizzying to say the least. Depression is grief. The difference is only that the person with depression has a Pavlovian trigger that is easily tripped or just stuck on. They have actually found comfort or a perverse subconscious pleasure in the act of grieving. Thus the grief like behaviors continue in a cycle. “The mind will always choose the path perceived as most pleasurable.” Even if that pleasure id derived from pain. It is the job, the psychoanalyst to try to track down that “trigger” and treat it at the source. I once had a conversation with a therapist in which we tangled over the statement, “children are resilient”. A most bogus statement especially from a mental health professional. Kids, like everybody else, are capable of repression. But just because an event or painful situation is repressed doesn’t mean it isn’t or won’t in the future drive their behavior. I said, “Isn’t that what your job is, isn’t that what people pay you to do, to dig into their subconscious and identify and treat the things they have long since repressed as kids?” (LOL, yes I am one really PIA patient.)
It causes grief to see such an obvious connection intuitively. And I can appreciate that one’s intuition is not scientific and has to be ascertained.
But of course “Depression will include normal grieving”.
It’s normal grieving that logically should not include depression.
After suffering the loss of a brother, two yrs. ago, I realized that I was not properly processing this loss. I was preocupied for far too long, and knew that I was getting into trouble, not being able to accept, and move on… I found myself showing signs of depression ( well known to me from past years ), and sought help. For whatever reasons, I didn’t receive the proper attention to my difficulties, and the greiving continued, as well as the depression becomming increasingly worse.
Less than one year later ( last yr. ) a second brother passed, again unexpectedly, and this merely complicated my mental health…Whether the depression was first, the grief & loss occured first, or in combination, at this point doesn’t matter. What mattered was that the therapists I employed did not allow me to work thru my grief( thereby perhaps aleviating depressive symptoms), would not allow me to address the feelings I was experiencing, and conswquently, I am now in a major depression.
After 4 psychologists, and two psychiatrists, I am now on an antidepresant, much too late for my comfort, but better than never.
To me, the whole mental health system needs an overhaul, never mind the diagnostic coding….these professionals need some updating on education, tools, and general caring of someone who is asking for help, rather than merely having their own self interest at heart, billing my insurance week after week. ‘Services Not Rendered’.
How about WE, as patients, have our own coding book, evaulatging the various therapists in the field?? Not by name, of course,but generally our experiences, and just who to stay away from, and who can be the most help?? How about our input into this whole system, allowing us to note just whom WE can trust?? After all, if you did not have us, you would not have any career, income, comforts, and prosperity
hi, I just wanted to leave a few comments. I fascilitate chronic pain workshops, support groups and sit on an education advisory panel. As you know up to 80% of chronic pain suffers have a form of depression with statistically up to 20% in a chronic state. Grief is a massive contributing to that depression in nearly all cases. They are grieving not just for someone lost, ie a death, but loss of their former self, who they identified as, loss of their relationships in life, loss of their ability to do and perform activities they once enjoyed, etc. In my opinion it can be the catalyst for all levels of depression and it is probably the most underdiagnosed and untreated form of depression. If you can put the brakes onthe catalyst the depression may not be a situation requiring long term medication and treatments. I truly hope people start to recognise this and deal with all forms of grieving as an illness and not as something to be sent to a church to deal with.