Health & wellness

In Practice

The relationship between grief and depression

Dan Page

After 50 years of marriage, Mr. F. died, and Mrs. F. was heartbroken. No, that’s an understatement: She was devastated. For weeks she cried, couldn’t sleep, couldn’t eat. Activities she usually enjoyed, like going out for lunch and volunteering at the local library, held no appeal. A warm, witty woman with an outsized grin, Mrs. F. - a patient of mine - had always arrived in my office dressed in bright pink, lavender, or red. Long after her husband’s death, Mrs. F. still wore black and gray, and both her wit and her grin remained absent.

Though she’d never suffered from depression before, and had no family history of the disease, Mrs. F. now seemed to meet the criteria for major depression set out in the Diagnostic and Statistical Manual used to define mental illnesses. According to the DSM IV-TR current edition, people are said to be in a major depressive episode if, for a two-week period, they have at least five symptoms from a list of nine, including lethargy, slowed speech and movement, difficulty concentrating, and decreased interest in normally pleasurable activities. Mrs. F had eight of the symptoms - and for far longer than two weeks. But the fact that Mrs. F. was grieving ruled out major depression according to the DSM IV-TR, which excludes the bereaved from this diagnosis.

Still, I urged Mrs. F. to consider taking an antidepressant. I hated to see her suffer and I worried about her health. Depression increases the risk of heart disease, especially in people over age 65. Also, though Mrs. F. said she hadn’t considered harming herself (the only one of the nine symptoms she didn’t have), depressed older people who live alone commit suicide at higher rates than the general population.

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But Mrs. F didn’t want antidepressants. She only wanted her husband back.

In my medical training, I learned that there are two distinct types of depression: major depression and situational (or reactive) depression. Major depression, I was taught, occurs for no apparent reason - its victims often have “nothing to be depressed about.’’ It results from an abnormality of brain chemistry, and responds best to drug therapy. In contrast, situational depression, my professors said, develops when someone suffers a loss or trauma. It’s treated with psychotherapy, not drugs.

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I hadn’t been in practice long before I realized that this distinction is not really so clear. I had patients with major depression who were only partially restored to health by antidepressants and needed talk therapy to fully recover. And I saw people who’d never been seriously depressed before thrust into what seemed to be major depression by a personal loss - and whose mood improved with medication.

Acknowledging that the line between depression and grief is blurrier than once thought, psychiatrists are now reconsidering whether bereavement should exclude a diagnosis of major depression. According to Dr. Naomi Simon, a Mass General psychiatrist who specializes in treating grief and depression, the American Psychiatric Association is debating whether to delete the bereavement exclusion in the next edition of the DSM. Additionally, a new diagnosis of “complicated grief,’’ for those with acute grief symptoms persisting at least 6-to-12 months after a loss, might be included in the DSM-5, to be published in 2013.

But diagnosing the bereaved as clinically depressed is controversial. Such a diagnosis risks rushing people through the grieving process, pathologizing normal human emotion, and even stigmatizing those who experience it.

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On the other hand, as Dr. Simon points out, grief can be as painful and disabling as any medical or psychiatric illness. She explains, “Bereaved individuals are often ‘stuck’ with difficulty moving forward with their lives or processing the loss.’’ Simon notes that severe and prolonged or, as it is called by psychiatrists, “complicated’’ grief has been associated with increased risk for suicide and post-traumatic stress disorder - even when the triggering loss or trauma is not as clearly catastrophic as the death of a spouse or child.

There is now a specific kind of psychotherapy available for patients with complicated grief. Mass General is one of four centers funded by the National Institute of Mental Health, doing a large randomized study examining the role of antidepressants alone or in combination with psychotherapy for complicated grief.

The question of whether severe grief is a “disease’’ is not new. Many of Shakespeare’s tragedies, most notably Hamlet, explore the border between grief and madness. In Shakespeare’s time and for centuries afterward, physicians were preoccupied with the connection of grief to melancholy, as depression was called. They could never quite agree whether melancholy was an extreme form of grief, or a completely different problem.

Kay Redfield Jamison, professor of psychiatry at Johns Hopkins, has been in a unique position to think about the relationship between grief and depression. As an expert in bipolar disease, and as a patient with this condition herself, Jamison has written extensively about depression from both scholarly and personal perspectives. Jamison has also experienced severe grief. Her husband, renowned psychiatric researcher Richard Wyatt, died after a long battle with lymphoma. In her memoir, “Nothing Was the Same,’’ Jamison recounts their extraordinarily happy marriage and the aftermath of Wyatt’s death.

In the chapter “Mourning and Melancholia’’ - borrowed from the title of Freud’s work on this subject - Jamison struggles to distinguish her grief from her past episodes of depression. She writes: “I did not, after Richard died, lose my sense of who I was as a person, or how to navigate the basics of life, as one does in depression.’’

But some do lose their sense of self and ability to function after a loss. This was certainly the case with Mrs. F. Gradually - over months and years - through the support of friends and family and her religious faith, Mrs. F. recovered. I still wonder if she might have been relieved sooner, with treatment.

Mrs. F. is now in her late 80s. She’s back to wearing bright colors, volunteering at the library, and grinning. She still misses her husband terribly, not in a way that impairs her, but with a lingering pain that no pill or therapy can erase.

Dr. Suzanne Koven is a primary care internist at Massachusetts General Hospital. She writes a monthly column about the uncertainties, dilemmas, and stories that patients and doctors share in practice. Read her blog on Boston.com/Health. She can be reached at inpracticemd@gmail.com.
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