Is Grief a Mental Disorder?

On Fridays I will address a question related to depression and find the answer from an expert. If you have a question you want answered, please ask it on the combox of this post, and I'll try my best to do some research and feature it in an upcoming Friday post.

A few Fridays ago, I asked the question: How is depression different from sadness? And I excerpted from a New York Times article written by Dr. Ron Pies, professor of psychiatry at Tufts and SUNY Upstate Medical Center in Syracuse. I was delighted to see him post a comment to my blog. He wrote:

To all who have commented on my New York Times piece, I would urge you to take a look at my much more detailed (and perhaps clearer!) explanation on the PsychCentral website. You can find it by clicking here.

In essence: Grief is not a disease, but it can become one. The issue is not whether we can point to a "cause" for someone's depressive symptoms, or whether we judge their reaction to be "normal" (from our own personal perspective). The issue is to what degree the person is suffering and incapacitated--whether or not we can point to some loss or other supposed "cause" for the way they feel. When suffering and incapacity become very great, the person merits professional help. This need not involve medication--but it does mean a careful evaluation and perhaps "talk therapy." In some cases, an antidepressant may also be helpful. There is no evidence that such professional help "interferes" with grieving or mourning, so long as the person is seeking help.

I appreciate his taking the time to write Beyond Blue readers, and inform us of his other piece, which allows more context to this very complicated subject. So here's this Friday's question: Is grief a mental disorder? I urge you to read the entire piece. Here's an excerpt:

I recently had an essay published in the New York Times (9/16/08), in which I argued that the line between profound grief and clinical depression is sometimes very faint. I also argued against a popular thesis that says, in effect, "If we can identify a very recent loss that explains the person's depressive symptoms -- even if they are very severe -- it's not really depression. It's just normal sadness."

In my essay, I presented a hypothetical patient -- let's call him Jim -- who was based on many patients I've seen in my psychiatric practice. Jim comes to me complaining of "feeling down" for the past three weeks. A month ago, his fiancée left him for another man, and Jim feels that "There's no point in going on" with life. He has not been sleeping well, his appetite is poor and he has lost interest in nearly all of his usual activities.

I deliberately withheld a lot of important information that any well-trained psychiatrist, psychologist, or psychiatric social worker would obtain. For example: in the past three weeks, had Jim lost a great deal of weight? Was he awakening regularly in the wee hours of the morning? Was he unable to concentrate? Was he extremely slowed down in his thinking and movement (so-called "psychomotor retardation"). Did he lack energy? Did he see himself as a worthless person? Did he feel completely hopeless? Was he filled with guilt or self-loathing? Had he been unable to go to work or function well at home, over the past three weeks? Did he have any actual plans to end his life?

I wanted to make the case ambiguous enough to be suggestive of clinical depression without "clinching" the diagnosis by providing answers to all these questions. (A "yes" answer to most of these questions would point to a serious bout of major depression).

But even given the limited information in my scenario, I concluded that people like Jim were probably better understood as "clinically depressed" than as "normally sad." I argued that individuals with Jim's history merited professional treatment. I even had the temerity to suggest that some grieving or bereaved individuals who also show features of a major depression may benefit from antidepressant medication, citing the research of Dr. Sidney Zisook. (If I had to write the piece all over again, I would have added, "Brief, supportive psychotherapy alone may do the job for many people with Jim's symptoms").

Well, my goodness! The blogosphere lit up like a swarm of fireflies. You would think that I had advocated the killing of the first-born! I should not have been surprised by the reaction from the "Hate Psychiatry First" crowd, who get their information about psychiatry from Tom Cruise. They wrote me off as either a shill for the drug companies [see disclosure], or someone who was "declaring grief to be a disease." One of the most irate bloggers opined that my medical license should be revoked!