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.