Martha is a 41-year-old manager in a manufacturing company and a mother of two. She presents with 1 month of insomnia 6 weeks after her mother died of a myocardial infarction. She had been very close to her mother and was glad she’d been with her when she died. Her doctor finds, however, that she’s feeling consistently sad, with diminished interest in things. Her appetite is a bit low, but her weight hasn’t changed much. Her concentration is “a bit off” and she finds it difficult to enjoy things fully, as her mind constantly returns to thoughts of her Mom. Her energy is “fair” and she doesn’t feel worthless or guilty. She’s managed to keep working, though at a diminished rate, and to care for her children.
Compare this with John, who lost his job a month ago. He presents with persistently low mood, crying spells, low energy and insomnia. He’s withdrawn from his family and for the last 3 weeks has been haunted by a feeling that his life is over and has no value.
Are both these people depressed? Would you offer antidepressants to either one?
The creators of the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) struggled to distinguish major depression from “normal sadness” — grief — in response to a loss. They suggested that symptoms of a depressive syndrome emerging within 2 months of the death of a loved one needed to have some of the following features
in order for a depressive disorder to be diagnosed:
Sadness is a normal response to many life circumstances. When does it become a disorder, worthy of clinical attention?
A recent study examined depressive symptoms after bereavement and compared them to symptoms after other losses, such as divorce or job loss, in a large population-based data set. (Am J of Psychiatry 2008;165:1449-55). They found 23 people who had depressive symptoms within 2 months of a loss of a loved one; 28% did not have the extra depressive features and so were diagnosed as having ‘normal grief.’ Fifty-five others who had stress-related depressive symptoms also did not have those extra features.
It’s a controversial feature of DSM IV that people who have lost someone may not be diagnosed with a major depression, while those who have symptoms related to another kind of loss, may be. The researchers found that of the remaining people (72%) with depressive symptoms after bereavement, 54 had psychomotor retardation; 46% had an episode lasting more than 2 months; 24% had severe work impairment; 20% had suicidal ideation. This picture was very similar to that of people with depressive symptoms following other adverse life events.
Similar findings have been previously made (Arch Gen Psychiatry 2007;64:433-40); but the two groups of researchers come to opposite conclusions: one suggests that the exclusion criteria for normal grief should be dropped completely, while the other suggests that the bereavement exclusion criteria should be extended to other life losses, raising the threshold before diagnosis of major depression.
The bottom line
People who experience losses vary in their reactions, from normal grief to a full-blown depressive episode. The DSM IV exclusion criteria flag those who likely have a depressive disorder and who may require treatment, including psychotherapy or medication. (There also are, of course, cases where normal grief reactions can lead to a need for psychotherapy.)
The available evidence suggests that people who meet DSM IV criteria for depression will benefit from treatment, whether or not the depression appears to have been triggered by a loss. The exclusion criteria can help clinicians identify cases of normal grief reactions, which call for more conservative management. This research suggests that they should perhaps be extended to other kinds of loss.
Martha was in the midst of a grief reaction that lasted about a year, though she never became more symptomatic.
John was in the midst of a major depression following the loss of his job. He was treated with psychotherapy and made a good recovery.
Barry L. Gilbert, MD, CCFP, FRCPC is a psychiatrist, psychoanalyst and Assistant Professor of Psychiatry at the University of Toronto.