MIND AND SPIRIT

Good Grief, or Bad Depression?

Do you remember the last time you were grieving? Maybe a loved one had died, or an important relationship had ended. Or maybe you had lost that dream job. Naturally, you felt very sad—but you may have been able to function reasonably well at home or at work. You were probably tearful at times, as waves of grief washed over you. At other times, you may have found yourself smiling at a cherished memory. You may have had trouble sleeping and concentrating, and your appetite was probably diminished. You may have felt less inclined to socialize than usual. And yet, when a friend or family member phoned or stopped by, you probably perked up for a while—only to feel those pangs of sadness a few hours later.

If all this rings a bell, you probably had what clinicians call “normal” or “uncomplicated” grief (if grief can ever be uncomplicated). After weeks or months, you may have found your mood, concentration, sleep, appetite, and desire to socialize bouncing back. Eventually, perhaps, you managed to look back on your loss with a calm sense of perspective. At that point, you were experiencing “integrated grief.”

All these experiences are normal—what the fifteenth-century monk Thomas à Kempis called the “the proper sorrows of the soul.” Ordinary grief is not a disorder, nor does it require professional treatment. Love, support, and “tincture of time” usually suffice. Yet this subject recently fueled an intense controversy among psychiatrists and many in the “grief support” community. The disagreement focused on a poorly understood rule in the official diagnostic manual for psychiatrists—the DSM-IV—and on whether the rule should be retained in the new DSM-5, which came out this year.

The so-called bereavement exclusion instructed clinicians not to diagnose major depressive disorder (MDD) within two months after the death of a loved one, unless certain serious features were present—such as suicidal intentions, psychosis, or markedly decreased ability to function. Supporters of the bereavement exclusion argued that many symptoms of MDD are to be expected after the death of a loved one; they didn’t want psychiatrists “medicalizing” a perfectly normal human reaction. They also worried that many normally bereaved people would wind up on antidepressants, with their attendant side effects, after a perfunctory evaluation by a general physician. Even experienced clinicians, they maintained, had a hard time distinguishing grief from major depression.

After years of debate, DSM-5 officials decided to eliminate the bereavement exclusion. They reasoned that when a patient meets all the usual criteria for major depression, the recent death of a loved one should not preclude the diagnosis of MDD. After all, they argued, a person can experience grief and major depression simultaneously—so why delay help for the depression?

Many mood disorder specialists, myself included, agreed with the DSM-5 decision. We argued that grief and depression, while sharing features like insomnia and decreased appetite, occupy different realms of experience. This concept is nothing new. Nearly two centuries ago, Rabbi Schneur Zalman of Liady distinguished between sorrow, or “constructive grief,” and melancholy, or “dejection.” His descriptions correspond very closely to our modern concepts of ordinary grief and major depression. But how, exactly, do these differ?

The normally grieving person maintains the hope that things will get better, and experiences pangs of sadness interspersed with positive feelings. In contrast, the depressive person’s mood is almost uniformly one of gloom, despair, and hopelessness, nearly every day—often accompanied by thoughts of suicide. The grieving person usually maintains a strong emotional bond with friends and family, and is often consoled by them. Severe depression usually makes one too self-focused and emotionally isolated to accept such comfort. The psychologist Kay R. Jamison has observed, “The capacity to be consoled is a consequential distinction between grief and depression.”

Sometimes, friends, family, or inexperienced clinicians mistake ordinary grief for major depression. More commonly, in my experience, signs of serious depression are inappropriately dismissed as normal, merely because they occur soon after the death of a loved one. Whenever the diagnosis is uncertain, I recommend evaluation by a specialist in mood disorders.

The good news is that both talk therapy and medication can help postbereavement depression. As for ordinary grief, we may actually become stronger as we heal from our loss and the fiber of grief gets woven into the larger tapestry of our life. As a rabbinical paradox puts it, “There is nothing as whole as a broken heart.”

Ronald Pies, M.D., is a clinical professor of psychiatry at the School of Medicine.