Is It Grief or Is It Depression?
In trying to explain what depression is like to people who have never been depressed, I ask them to recall how they felt when they suffered a personal loss, such as the death of a loved one. It may not be depression, but it’s a very good approximation.
Nevertheless, there is a very huge difference. Grieving is a perfectly normal, even healthy, response to personal loss, and the DSM-IV is quick to separate this kind of depression from the real thing. In the words of the DSM:
“The symptoms are not better accounted for by bereavement ...”
It’s as if our profound sense of emotional pain has a purpose. We may fall to pieces, but instead of isolating we reach out and connect. We may rage against fate, but instead of feeling helpless and hopeless, we often experience cathartic release. Eventually, we pick up the pieces, eventually we become whole.
We may carry the loss forever, but we manage to bear the load. We may feel an empty space in our heart, but we manage to find an accommodation in our soul.
But where is the meaning in depression? In my daily blog on Knowledge is Necessity, I raised this question, based on a thought-provoking article by Jonah Lehrer in the NY Times: Does our suffering have a purpose?
No, was the overwhelming response from my readers. As Julia explained:
It's one thing to think about how to make the best of depression and cull what wisdom you can from your experiences, but I would hardly call it a path to wisdom.
The best I could come up with is that my milder depressions calm my mind and set the scene for insightful ruminations. And that my severe versions may force my mind into a kind of protective hibernation that shields me from a world I find too much to bear.
But what would cause me to think that life is too much to handle in the first place? Unless I suffered some kind of personal loss, then and only then does depression seem to make sense. It’s as if clinical depression - our brains quitting on us out of the blue - is our grief response gone wrong. The mind flips into grief for no reason. No reason.
But wait. Does that mean that if we are feeling a force-9 depression due to personal loss we shouldn’t be treated for depression?
Last month, the DSM-5 task force, issued its proposed revisions to the next DSM, due out in 2013. Missing is the bereavement exclusion. In other words, according to the work group that prepared the new draft diagnosis, a depression is a depression is a depression. Or, at the very least, there is nothing to distinguish a depression resulting from loss of a loved one from a depression caused by loss of a job or a marriage.
The reasoning is based on the work of Sidney Zisook of UCSD, who argues that ignoring bereavement-related depression risks depriving treatment to individuals who need it.
Nonsense, says Allen Frances of Duke University who headed up the DSM-IV published in 1994. According to Dr Frances:
Medicalizing normal grief stigmatizes and reduces the normalcy and dignity of the pain, shortcircuits the expected existential processing of the loss, reduces reliance on the many well established cultural rituals for consoling grief, and would subject many people to unnecessary and potentially harmful medication treatment.
The current DSM and the draft DSM-5 provide a firewall of sorts in the form of a two-week minimum for an episode of depression. Dr Zisook makes a case for extending the minimum to three or four weeks. Nearly all of us who experience grief are through the worst of it by then. But not all of us.
The DSM-II of 1968 distinguished between what it saw as biologically based depression and depression as a reaction to events around us. The distinction was a naive one, as it assumed a mind-brain separation. The DSM-III of 1980 wisely eliminated the distinction, but new advances in brain science make a good case for bringing it back in the form of some sort of reactive depression, but as a condition mediated by the brain. In a nutshell:
For most of the population, our genes predispose us to resilience. We bounce back from stress, trauma, bad luck, and loss. Some of us, though, are vulnerable, and this applies to practically all of us with bipolar. In response to what life happens to throw our way, our fear circuits overload and override the thinking part of the brain. Key parts of our frontal cortex literally go offline and cede dominion to the reactive gray matter sitting above the brain stem.
We lose the power to think, to control our emotions. In the case of grief, our brains lock onto one thought and can’t let go. We fail to bounce back. We continue to stay depressed, for months, for years ...
In this sense, bereavement-related depression is no different that any other stress-related depression. The catch is the current DSM does not recognize stress-related depression as a different species of depression and neither will the next one. It stands to reason that different causes imply different treatments and therapies, and there are some study findings that suggest this.
But for right now, we have no definitive answers. When does a normal response to loss turn abnormal? And can one truly lump that abnormal response with clinical depression as we know it? Your lived experience is as good as any expert opinion. Tell us what you think. Comments below ...