Grief and depression have similar symptoms. With new changes in psychiatric diagnosis definitions, the two will increasingly overlap.
Declared complete, the fifth edition of the Diagnostic and Statistical Manual (DSM) is slated for release in May, but debate continues to surround some of its more controversial changes -- specifically, the elimination of the old DSM's "bereavement exclusion" in diagnoses of major depression disorder (MDD). People in mourning often have similar "symptoms" to people with depression; the exclusion was originally intended prevent psychiatrists from diagnosing someone with MDD before they could be sure that the symptoms they were seeing were more than the usual manifestations of grief. Now, psychiatrists will no longer be advised to wait two months after a patient loses a loved one, for the period of "normal" grief to pass, to diagnose mental illness -- and prescribe antidepressants.
Writing for the New York Times' philosophy column, Gary Gutting frames this as a moral issue. For "normal" grievers and those for whom a loss has triggered an episode of depression, he argues, "The suffering may be the same, but suffering from the death of a loved one may still have a value that suffering from other causes does not." He insists, "No amount of empirical information about the nature and degree of suffering can, by itself, tell us whether someone ought to endure it." He argues that psychiatrists, as medical doctors, aren't qualified to make this decision.
The grieving process gets close at what it means to be human; it's understandable that handing it over to professionals armed with pills approaches the most dangerous misuse of pharmaceuticals we can imagine.
But Gutting writes, of those in favor of eliminating the exemption, that "They offer evidence that normal bereavement and major depression can present substantially the same symptoms, and conclude that there is no basis for treating them differently."
He's right about that first part -- major depressive disorder is one of the least reliable diagnoses in both adults and children, and so far as the "emotional" symptoms -- intense sadness, trouble eating and sleeping, difficulty concentrating -- are concerned, can closely resemble grief.
But as Ferris Jabr painstakingly described last week in Scientific American, depression and grief are two entirely different experiences:
Whereas depression is usually constant, grief is more likely to ebb and flow in waves and it does not usually invoke the feelings of worthlessness and low self-esteem that are so characteristic of depression. Grievers long to be reunited with someone they loved; the depressed often believe that they are unlovable.
The two are in fact so different in essence, if not appearance, he shows, that it's possible to suffer from both simultaneously.
The question, then, is would prescribing antidepressants to someone in mourning -- but not suffering from depression -- in any way alleviate their pain? If it did, and thus made the "natural process" of grieving easier or shorter, the moral dilemma invoked by Gutting would be pertinent.
I asked Dr. Richard Friedman -- who last May penned an editorial in the New England Journal of Medicine that opposed what he framed as the DSM-5's move toward making grief a clinical condition -- whether people in grief would benefit from antidepressant medications. "It isn't clear. It really isn't clear," he told me. As yet, the potential effects of treating grief in the same way we would depression have not been studied.
The experience of grief for a loved one is something we hold to a higher standard, and to which we assign utmost importance -- more so, than, say, grief for a lost job or for a friend who moves away. But we do not think of depression as being nearly so sacred. An episode of depression can be triggered by a personal loss, but it can also arise out of seemingly nowhere, or in response to "lesser" triggers, like a lost job, or a friend who moves away.
"Once you develop the phenotype 'depression,' and have all the biological changes in your brain that go along with it, it's the illness," said Friedman. He likens it to pneumonia -- whether you got it because you are immunodeficient or because you spent too much time out in the rain, the end point is still the same. "And in a way," he said, "the conditions that led you to the infection are not relevant anymore -- now you've got the infection and it's got to be treated."
Where the mourning process does enter the clinical realm is with something known as "complicated grief," which occurs in about 10 to 20 percent of mourners and defines a grieving process that is not normal but is also not depression. Grief, of course, can last a lifetime, but complicated grief that doesn't assuage over time.
Both it and depression warrant quick intervention -- both conform to the illness narrative, and, with the risk of suicide, can even be life threatening. Psychiatrists will now be in a position to decide much sooner whether patients are suffering apart from, and beyond, normal grief. This means that patients with MDD will get help sooner. But the consequences that may come from mistakenly treating grief in the absence of mental disorder remain to be seen.