Monday, March 25, 2013

The Difference between "Grief" and "Depression"

From 1 Boring Old Man:

  • Phenomenology: This comment summarizes the phenomenologic differences; "the hallmark of grief is a blend of yearning and sadness, along with thoughts, memories and images of the deceased person, while in contrast, depressed people ‘see themselves and/or the world as fundamentally flawed, inadequate or worthless.’ In essence, the psychological pain in ‘normative grief’ emerges from loss of the ‘other’ – and self-esteem is almost invariably preserved in the early stages – while the central characteristic of depressed states is compromised self-worth. The phenomenological distinction is sharp."
  • Natural History: Depressive illnesses tend to recur. He cites ample evidence to show that grief does not recur, nor does it predispose to future depressions.
  • Staging: Another summary quote, well referenced; "Staging is another important distinction. While clinical depression may be presaged by warning signs or symptoms, and it may have a slow or abrupt onset, it generally lacks the stages integral to grief."
  • Treatment Response: "Turning to treatment specificity, Shear expressed a common argument in stating that ‘depression requires treatment and grief requires reassurance and support’. The evidence base for antidepressant medication is convincing in relation to major depression – but is limited for the management of grief and often contingent on other factors, predictably including the presence or absence of a superimposed depression." If I may quote my friend who was prescribed Elavil when he was grief stricken, and I later asked him what it did for him, he replied, "It made me constipated."
I appreciate the clarity of this article. I wouldn’t have been able to parse the differences so crisply. To me, grief and depression are just different things [I think one can often distinguish them without even taking a history, though I'm not sure that such empathic communication is kosher in the DSMs].

The pandora’s box in this article is highlighted in red above. Parker suggests that many reactive depressions would fit better with grief than Major Depressive Disorder – that instead of broadening MDD, we should be moving in the other direction and limiting the use of this diagnostic category. He says this a suggestion, "Rather than drawing bereavement within the domain of the clinical depressive disorders (as DSM-5 appears still to favour), we might better lean the other way and consider whether many currently positioned clinical depressive disorders (especially the reactive depressive conditions) might fit more comfortably within a grief paradigm."

I would see this as more than a suggestion, rather something in the range of a mandate – an imperative. The removal of the Bereavement Exclusion is more than just a another goofy change to the DSM-5, it represents a bias that pervades the whole enterprise – diagnostic expansions that don’t medicalize the DSM-5, they dehumanize it…
What I find worthy to note is that "reactive depression" is basically "grief", or put in other words it is an depressive reaction to an cause of grief (which can be a chronic disease). And that this "reactive depression" may look similar at first glance to "depression" (as in "Major Depressive Disorder"), but is something different.

If you have an chronic disease and a co-morbid "reactive depression" (possibly caused by the disease), you can learn to cope. Learning to cope with your chronic disease. And learning to cope with your grief over your chronic disease.

If on the other hand you have a chronic disease and a co-morbid "major depression", trying to cope will not help you much with the depression.

And same as with the distinction between "fatigue" and "sleepiness", the distinction between "grief" and "depression" is an important one.

(However I don't have the impression that medical science knows how to deal with depression, no do I think that medical science has a clue about it causes. I'm confident that the causes of depression are nutritional in many cases, so we'll see how that plays out.)

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