Grief Versus Depression

This past Sunday, August 15, 2010, Dr. Allen Frances, MD, wrote an article in the opinion section of the Sunday New York Times entitled, "Good Grief." Dr. Frances has very impressive credentials. He is an emeritus professor and former chairman of psychiatry at Duke University and was on the task force that created the DSM IV.

In the article, Dr. Frances expresses concern about the idea that is being considered for the DSM V, that runs the risk of treating many grief reactions as abnormal and in need of medication and treatment. This is a concern that I share with him.

In my experience as a Licensed Clinical Social Worker and psychotherapist for over thirty years and in my personal life, I have learned that people have a wide variety of reactions to the death of a loved one. In addition to tearfulness and weeping, among the emotional and physical reactions to loss that I have witnessed in private practice and private life are:

Emotional Reactions:

1. Denial,
2. Sadness,
3. Anger,
4. Confusion,
5. Despair 
6. Guilt.

There is no order or combination to the ways in which these occur.

Physical Reactions:

1. Sleeping problems,
2. Changes in appetite, 
3. Drop in energy level,
4. Body aches and pains,
5. Development or worsening of an illness such as a virus.

Often, there are unrealistic ways of thinking about the death of a loved one, such as, "I could have prevented this death if...," "I could have called him back from the edge of death while he lay in a coma," "If I had been a better person this would not have happened," and many others.

There is no doubt that grief is a wrenching experience that brings people to the edge of despair, hopelessness and depression. However, does this mean that the person in grief is depressed?

What I believe Dr. Frances is saying and what I assert, is that the answer is no, grief does not mean depression except in a small number of cases in which the individual crosses the boundary from grief into major depression.

How can the difference between normal grief and major depression be distinguished?

Generally speaking, a grieving will mourn for approximately one year. During the course of the first year after a loss, most people go through a gradually decreasing number and intensity of emotional reactions. Slowly but surely, people return to their ability to function, including the ability to return to work, meet with friends, sleep, eat regain equilibrium.

However, there are those individuals who do not recover their functioning and who remain fixed in a level of grief and sorrow that last well beyond one year. Among these are those with a prior history of depression or who now slip into depression. They experience very active suicidal thoughts that may include suicidal plans. There are, at times, the fantasy that they can reunite with the loved one by committing suicide. There is a depth of misery that saps energy one two and three years after the loss. Hopelessness takes over and never leaves. These are the people who need to be treated with anti depressant medication.

In my opinion, it would be a tragic mistake to include grief in the category of mental illness and that needs to be treated.

What is your opinion and experience? Your comments are strongly encouraged.

Allan N. Schwartz, PhD