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Losing a loved one is inevitable for most people, and grief is a universal response to such a loss. Yet how people grieve, and for how long, is anything but universal. The popular concept of discrete “stages” of grief lacks support from empirical data; individuals vary greatly in their response to bereavement due to cultural, spiritual, biological, and even genetic differences.
The interrelationships between grief and depression, a clinical disorder often termed Major Depressive Disorder (MDD) or clinical depression, are multifaceted. Extreme sadness and disengagement from the world are common features in both, and depression may co-occur with grief. Grieving can both trigger a depressive episode and be prolonged by depression. Like other major life stressors that can trigger MDD, such as divorce or the loss of a home or job, a depressive episode associated with bereavement can increase the risk that depression will recur, though some data suggest that the recurrence risk is lower than that associated with other stressors.
For at least 100 years, psychiatric science has been trying to sort out how–or if–grief differs from depression. In his 1917 essay “Mourning and Melancholia,” Freud acknowledges similarities between the presentation of grief and what is now called MDD, but emphasizes their fundamental differences. Mourning is a healthy and normal process necessary for recovery from loss and should not be seen as a pathology nor require medical intervention, Freud wrote, whereas melancholia is an abnormal pathology that poses a danger due to its elevated suicide risk.
In her heart-wrenching 2009 memoir “ Nothing Was the Same,” about the death of her beloved husband, Alain, Johns Hopkins psychiatrist and Dana Alliance for Brain Initiatives (DABI) member Kay Redfield Jamison, Ph.D., eloquently describes the distinction she felt between the transient ebb and flow of grief vs. the unrelenting self-loathing darkness of depression, a condition she knew well from her own struggles with bipolar disorder. “Grief, as it transpires, has its own territory,” she wrote.
DSM-5 Change Sparks Controversy
In more recent years, the psychiatric community has debated the question of how to parse grief from depression in the context of a change to the standard diagnostic criteria for major depression. The DSM-5, the most recent edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (published in 2013), no longer treats recent bereavement as an automatic exclusion to diagnosing MDD, sanctioning a diagnosis of depression even in people who have just suffered the loss of a loved one. The removal of the “bereavement exclusion” was one of the most controversial and hotly debated updates the DSM task force considered.
The argument for the change largely centered around the idea that grief is not unique from other life stressors as a potential precipitator of depression, so it didn’t make sense to single out bereavement, as DSM had beginning with the third edition in 1980. Sidney Zisook, M.D., a psychiatrist at the University of California at San Diego served as an ad hoc advisor to the DSM task force in relation to the bereavement exclusion and argued for its removal. He contends that “Bereavement as a stressor is not different from other stressors that might trigger a depressive episode.”
Another concern was that the post-death exclusion period might leave people vulnerable to suicide simply because of a somewhat arbitrary time bracket based on little data. After a contentious debate in and outside psychiatry, the DSM committee concluded that the best available science did not support the bereavement exclusion and replaced it with a footnote guiding a diagnosis of MDD in the context of grief and loss.
The move set off a firestorm within psychiatry that exploded onto headlines in the lay press (see an overview here.) Many critics lambasted the move as “medicalizing” grief, turning a normal behavioral response to a profound life stressor into a mental illness and thereby opening the floodgates for antidepressant marketers to take aim at grief. New York University psychiatrist Jerome Wakefield, DSW, Ph.D., one of the most vocal opponents of the move, dismissed the task force’s arguments as false validity and warned that the change “would massively pathologize normal grief responses.”
Like others, neuropsychiatrist Eric Nestler, M.D., Ph.D., Icahn School of Medicine at Mount Sinai and a member of DABI, worries that the DSM change will encourage over-prescribing of antidepressants. The field of psychiatry as a whole has been “too fast to put people on medications,” he says.
“I’m a big believer in antidepressant medications–it is my field of study–but I think we use them too quickly,” Nestler says “I think the whole medical field has gotten to the point where there are just too many pressures to prescribe an inexpensive antidepressant medication when someone comes to us with a problem they’re having in life, rather than taking the time to teach the person how to cope.”
For his part, Zisook rejects the idea that removing the bereavement exclusion sends a message that it’s okay to medicate grief and contends that dire predictions that the move would lead to a flood of antidepressant prescriptions for grief, or that drug makers would seek to add an indication for grief to the list of conditions antidepressants treat or otherwise market their products to the grief-stricken, have so far not materialized. The fears around medicalizing bereavement have been overblown, he says.
Grief vs. Depression: Similar but Different
DSM-5 attempts to clarify the clinical differentiation between typical grief and MDD while acknowledging overlapping symptoms such as weight loss, insomnia, rumination, or poor appetite. DSM-5 criteria emphasize that in grief, the prevailing affect is one of emptiness, while MDD is marked by a long, sustained depressed mood and an inability to ever expect pleasure or happiness. Grief typically comes in waves that lessen in intensity and frequency over time, while a depressed mood is more persistent. People who are grieving are likely to retain feelings of self-worth and self-esteem and may still experience positive feelings, including humor, while such emotions are generally not seen in depression. In grief, any suicidal or negative ideation that occurs generally revolves around feelings of guilt or a desire to “reunite” with the deceased, whereas in depression such feelings are more likely to be directed at oneself.
The DSM-5 also examined the clinical importance of unresolved grief. While most people are able to eventually integrate a loved one’s death into their lives and move into a “new normal” without that person’s physical presence, for others the grieving process stalls or goes awry. The resulting condition includes persistently intense acute grief symptoms, such as yearning and longing, in concert with other strong emotions and complicating problems, such as rumination, avoidance, or ineffective emotion regulation. When the symptoms and functional incapacity commonly associated with acute grief persist beyond typical time frames, they can cross a line into a grey area at the extreme of normal that psychiatrists variously call “complicated grief,” “persistent complex grief,” or “bereavement-related depression.” At this level bereavement may look much like major depression clinically and may warrant interventions to reduce associated risks such as suicidal thoughts and actions. Notably, even “uncomplicated” grief may develop into an acute depressive state, further blurring the line between typical and atypical grieving.
The DSM-5 committee found insufficient evidence to support a proposal to classify “complicated” grief as a mental illness for the first time, and instead added Persistent Complex Bereavement Disorder to the Appendix as a “candidate” disorder that deserved further study.
A Problem for All of Psychiatry
The problem of where to draw that line between “normal” response and pathological behavior is one that plagues all of psychiatry, because objective measures that clearly differentiate between pathology and normal are lacking. As Mental Health Counselor Kenneth Doka, Ph.D., a sociologist and author at College of New Rochelle, puts it: “All mental illness is an intensification of a normal reaction.” Only when the reaction reaches the level of significant impairment does the behavior cross the line into “illness.” Not everyone agrees where that line is, as the debate surrounding the bereavement exclusion demonstrates.
“At what point after that normal period of grief does it become pathological?” asks Nestler. “There’s no answer to that question today; it’s just a best estimate of what we have.”
Given the overlap and interrelationships, disagreement over diagnosis will no doubt continue as psychiatry grapples with questions like whether complicated grief warrants psychiatric intervention or medication, and how it relates to risk for later depression. Zisook predicts that the next update to the DSM, as well as to a separate diagnostic guide, the International Classification of Diseases (ICD), will likely include some classification of complicated grief as a mental disorder, all but guaranteeing another round of debate.
Until there are better ways to diagnose and differentiate mental illnesses based on the underlying neurobiology, controversy like that surrounding the grief vs. depression debate isn’t going away. Unfortunately, such advances have not been so forthcoming as many experts had hoped.
“Thirty years ago, I would tell everybody that the application of molecular biology to psychiatry will yield important insight into the causes of mental illness as well as new treatments within five or ten years,” says Nestler. “Here we are 30 years later, and we haven’t seen those improvements. I think it’s important that we acknowledge that and come clean on that frustrating pace of progress while at the same time hold out hope that we’ll get there.”
“I still believe we will get there,” he adds. “It’s just that the brain has proven to be a lot more complicated than we ever thought, and the disorders of the brain have proven to be a lot more complicated than we ever thought.”