The Fine Line Between Grief And Depression
The Fine Line Between Grief And Depression
For years, therapists and medical professionals avoided diagnosing major depression in people who have just lost a loved one in what's known as a "bereavement exclusion." But a new proposal for the American Psychiatric Association's diagnostic manual would eliminate that exception.
Tammy Blackard Cook, licensed clinical social worker and therapist for Aspire Group
Dr. Michael Craig Miller, psychiatrist and editor in chief, Harvard Mental Health Letter
JENNIFER LUDDEN, HOST:
This is TALK OF THE NATION. I'm Jennifer Ludden, in Washington. Neal Conan is away. Losing a loved one is, simply put, painful. Such separation brings extreme sadness that can feel sometimes too heavy to bear. The Irish writer C.S. Lewis chronicled his suffering and healing after his wife died of cancer at the age of 45.
In "A Grief Observed," he reflects: Bereavement is a universal and integral part of our experience of love. The American Psychiatric Association, or APA, and its diagnostic manual has longed warned doctors away from diagnosing major depression in people who've just lost a loved one. It's known as the bereavement exclusion in the DSM, or the Diagnostic and Statistical Manual of Mental Disorders.
But a proposed change in a draft of the DSM's next edition, due out next year, eliminates that bereavement exclusion, and this has posed many questions in the profession.
We'd like to hear from our listeners. If you're a therapist or a psychiatrist who's treated grief, where do you draw the line between grief and depression? Share your experience. Our number is 800-989-8255. Our email address is firstname.lastname@example.org, and you can join the conversation at our website. Go to npr.org and click on TALK OF THE NATION.
Later in the program, the comedy duo of Key and Peele on race, stereotypes, humor and their new show on Comedy Central. But first, how we treat grief. Tammy Blackard Cook is a licensed clinical social worker who provides therapy and counseling for Aspire Group in Raleigh, North Carolina. In her blog, she's also written about her own grief. Last year, her father died of lung cancer. Tammy Blackard Cook joins us now from member station WUNC in Durham. Welcome. Thanks so much.
TAMMY BLACKARD COOK: Hi. Thanks for having me.
LUDDEN: And condolences for your loss.
COOK: Thank you.
LUDDEN: Can we just ask you about that first? Tammy, after treating people as a professional, treating people for grief, what did you learn when you went through a grieving process yourself?
COOK: Oh, so much. I mean, certainly, I've been through grief before, but not, you know, the loss of someone so close to me. You know, it's the first time I'd lost a parent or, you know, sort of that generation. Before that, it had only been grandparents.
I guess it sort of confirmed what I'd always assumed, you know, in listening with my clients and sort of hearing their experience and walking with them through their grief. You know, it's just - it's incredibly hard, and it is overwhelming. And - but it is what it is.
You know, you have to accept that grief as part of life and death as part of life. And, you know, I sort of - one of the things I say to my clients - and I try to follow my own advice - is you kind of have to lean into it to kind of make your way through it. But I know in America, a lot of times, we just want to feel better.
You know, we try to do things to avoid feeling bad, any sort of negative emotions like grief or sadness or that kind of thing. And, you know, it just doesn't work. People...
LUDDEN: Were you more sympathetic to that, though, when you were going through it yourself, in a way?
COOK: Yes. Yes and no, I guess. I guess that's why we go into being therapists. You know, I feel like I'm pretty attuned to how people feel, and, you know, can really sort of - I guess, in some ways, be with them and sort of hold a safe place and I think have some understanding, some, you know, intellectual understanding, but also some other kind of understanding, if that makes sense. And so, like I said, I think it just confirmed what I always had gotten from my clients.
LUDDEN: And did it change your treatment of others? I mean, did it change the way you deal with your clients after having gone through the death of your father?
COOK: For me, no. I can see that it really would with some other folks and some folks I work with. I mean, we sort of talk about that sometimes. They haven't had that sort of firsthand experience with grief. But, I mean, on the other hand, I mean, to be fair, we knew that my dad would probably have a recurrence. That's just the way lung cancer is.
And I think for - he had it for 10 years, and he was fine. So I think I'd been sort of steeping myself for a long time. And maybe in that 10 years, that had made me a lot more attuned with my clients who were going through something like that.
LUDDEN: We're also joined by Dr. Michael Craig Miller. He's been a practicing psychiatrist for more than 30 years. He's the editor-in-chief of the Harvard Mental Health Letter and an assistant professor at the Harvard Medical School, and he joins us from member station WBUR in Boston. Welcome to you.
MICHAEL CRAIG MILLER: Thank you very much for having me.
LUDDEN: Can I ask you: Where - when do you know that a patient's grief has become a major depression? Where do you draw that line?
MILLER: The reality is that there is no firm line, and it is always a judgment call. Personally, I understand the debate about the bereavement exclusion, but I think our interest as clinicians is often simply to be practical. And my advice often to people who are going through this is that - if that you think you may be depressed, then it is probably worth having a conversation with somebody in a position to help.
And, again, the - there's a variety of needs to classify things, to categorize illnesses. But on the personal level, the labels tend not to matter as much as the practical concern, that people shouldn't feel a sense of shame, if they feel they need some help to get through something, to ask for it either from a family member or from a minister or a rabbi or a primary care doctor or a therapist or a psychiatrist.
And everybody's story is unique. Everybody's way of grieving is unique. And so the categories, which are interesting to debate, tend to be less important for the individual going through the loss.
LUDDEN: Surely. But as a professional, what are - are there signs you look for that distinguish one from the other? Because I don't know that I could. You know, I have not had a person very close to me die. I cannot say I've gone through this kind of grief. But I'm imagining I would be hard pressed to distinguish despair...
MILLER: You know, you're absolutely right. And this is as difficult for professionals as it is for people who aren't practicing clinicians. You know, the symptoms - if you want to call them symptoms, but the description of grieving looks very much like depression. People cry. They feel depressed. They're having trouble sleeping. They may not have an appetite. They may not feel like doing anything. They may not take pleasure in anything.
It goes down the list, and it looks very much like what we describe as major depression. And what professionals have done is to try to put an arbitrary timeframe on it. So in the prior version, the current version of the DSM, there's a statement that it should be at least two months, but - with those symptoms. But as many have pointed out, those symptoms can continue for six months, for a year, for longer.
It depends on the culture. It depends upon your family. It depends upon who you are and how you manage loss, and it - you know, so we use the guidelines, and I think that if - I mean, again, being practical, if you needed a cutoff, if those symptoms were going on for longer than six months, then you might turn to a family member and say, gee, this may be more complicated than - not that losing a parent or a spouse is ever easy, but there's a certain point where the symptoms to persist, and the inability to get out and go to work or live your life after a certain period of time, we have a variety of ways of trying to help people get back into their lives.
And, you know, I liked what was said earlier about leaning into it, that the ultimate goal, I think, rather than getting over it is to remake your life in a new form after somebody you've lost has been lost.
LUDDEN: All right, let's get a call in, here. Brian is in Hickory, North Carolina. Hi there, Brian.
BRIAN: Yes, hello. Thank you for taking my call.
LUDDEN: Go right ahead.
BRIAN: Well, when I heard the topic, I just thought maybe I could make this contribution. I've had about 15 years of interacting with folks as a chaplain, both in hospice and in a hospital setting. And whether someone is lost suddenly in an ER or an operation gone wrong or in a hospice setting where you know the death is coming, I find that afterwards, the greatest challenge is just like your speaker just said, that it's trying to help equip or empower the grieving person to reset their life and to continue to live the, quote, "normal life" that they currently have.
And I see depression as, you know, if you're trying to distinguish the two, I see depression as showing itself when someone just comes to a dead stop - dead stop - comes to a complete stop and is unable to do their day-to-day things and just can't take on that necessary task of creating a new life for themselves.
LUDDEN: Whereas in your experience, people who are grieving can keep showing up at the office at all? Although isn't that very individual, also?
BRIAN: Oh, absolutely. But I guess - again, you know, when I heard that DSM was thinking of taking off this exception, I find that grief is absolutely normal, and it's only appropriate that a person allow the symptoms that are just a part of our humanity to show themselves in great depth.
I mean, we have to cry. We have to be silent and quiet for a time. If someone just goes forward without, quote, "showing the symptoms," I don't - that, to me, is mental illness. I mean, appropriate health is to stop and acknowledge that something profoundly significant has happened to you.
LUDDEN: All right, Brian, thanks for the call. Tammy Blackard Cook, you're agreeing there.
COOK: Yeah. No, I've actually agreed with everything that's been said. Yeah, I think that - I get hard-pressed to want to give anybody a diagnosis of major depressive disorder, you know, any time under a year. I mean, I know what the DSM says, and it is an arbitrary, you know, timeline because everything that's been said is true.
You know, it is - the symptoms of depression are very, very similar to the symptoms of grief, and, you know, there are periods of time - especially early, early on, when people do have a hard time functioning. And so, anyway, in my practice, you know, practically - which is what I liked what the doctor said, was, you know, I wouldn't necessarily diagnose someone with that early on, and I would probably wait at least a year.
LUDDEN: And we're going to continue this conversation in a moment. We're talking about the line between grief and major depression. If you're a therapist or psychiatrist, give us a call: 800-989-8255. Or email us at email@example.com. I'm Jennifer Ludden. This is TALK OF THE NATION, from NPR News.
(SOUNDBITE OF MUSIC)
LUDDEN: This is TALK OF THE NATION from NPR News. I'm Jennifer Ludden. There is an ongoing debate among psychiatrists over what constitutes normal grief and what deserves a diagnosis and treatment as major depression. The argument centers on a proposed change in a draft of the next edition of the DSM, that's the Diagnostic and Statistical Manual of Mental Disorders.
We're talking today not about the specifics of that debate but about the process of grief. If you're a therapist or psychiatrist who's treated grief, where do you draw the line between grief and major depression? Share your experience. Our number is 800-989-8255. Our email address is firstname.lastname@example.org, and you can join the conversation at our website. Go to npr.org, and click on TALK OF THE NATION.
Our guests are Tammy Blackard Cook, a licensed clinical social worker who provides therapy and counseling for Aspire Group in Raleigh, North Carolina; also Dr. Michael Craig Miller, a practicing psychiatrist for more than 30 years. He serves as editor in chief of Harvard Mental Health Letter and is assistant professor of psychiatry at Harvard Medical School.
We have an email from Lalane(ph), who writes - Lelani(ph) rather, who says that the grief over the loss of her mother impacted her daily life in a debilitating way for quite a time. I was offered pharmaceuticals, she writes, but I thought it was something I had to go through and did not want to mask my emotions, memories or thoughts. I was in a fog for four-plus years.
Dr. Michael Craig Miller, what about the notion that this is something that we need to go through, you know, the seven stages, right, isn't that what it's supposed to be?
MILLER: Well, everybody has a different idea about the stages and categorizes them. And I think that, you know, one of the things that we've learned since Dr. Kubler-Ross, years ago, talked about five stages, and other people have come up with seven, that we really don't go through this in a linear way. We don't go through this from one stage to the next without any back and forth.
It can take months. It can take years, and I think what the - I liked very much what the chaplain caller said earlier about this notion of being stuck or not, of being stopped in your tracks.
LUDDEN: Able to function, he talked about, how can they function.
MILLER: Right, and, you know, I think that loss of this sort is inevitable. We all go through it. It's - and it's - I mean, you know, there's this old line about turning a crisis into an opportunity, but this is really something different, that we have to, in a way, grow with experiences like this.
We learn things about ourselves, and the emailer who talks about being the keeper of memory, I think that - one of the reasons - one of the people who has been vocal about this complicated bereavement exception is Dr. Arthur Kleinman, who wrote an article in the Lancet recently, where he talks about - he quotes this notion of being the keeper of the memories of the person who's lost.
He lost a spouse after a long marriage, and so what the writer talks about is being sort of the keeper of the memory of her mother. Another thing it might be worth raising is that if you've been in a care-giving position with an aging parent, then it's much more complicated because the caring for the parent, the caring for the spouse, is part of the structure of your life, and it may actually be harder to move forward in your life if not just the loss of the person but the loss of the structure of day-to-day life.
And, you know, if taking care of an aging parent has really provided you with a sense of day-to-day meaning, that's another kind of loss. So these losses are really quite textured and different and depend so much on the circumstances.
LUDDEN: Tammy Blackard Cook, taking that maybe as an example, are there - can you offer others? Again, what do you look for? You know, how do you distinguish grief and depression?
COOK: Well, the one point I wanted to raise - and I hope this answers your question, but I guess for me in my work day to day, you know, if someone comes in, and they're having a hard time, you know, they lost someone, they're going through grief and that kind of thing, I don't always see my job as necessarily having to switch whatever diagnosis I may have given them when they walked in the door to major depressive disorder in order to say to them, you know, hey, at some point down the road, you know, maybe a few months if things haven't really started to get a little better for them, hey, have you considered medication because certainly we send people to get evaluated for medication all the time.
But I don't necessarily think that I have to then change their diagnosis to major depressive disorder. So I may, for an example, I may have diagnosed them with adjustment disorder with depressive symptoms, which seems more, I don't know, right to me because, you know, grief is hard, right.
And I like to give people the example - your emailer made me think of this as something I tell clients a lot: Nobody wants to go on medication, nobody does, right? And sometimes, you know, the thing about medication - and I was reading all this stuff last night, and I found it fascinating, but the thing about most of my experience with my clients and the medication is that it doesn't make it better.
It doesn't take away your grief. I mean, it makes it better, sorry, but it doesn't take away your grief. You're still very sad. You're still very caught up in it, but it just sort of takes the edge off. And Elizabeth Gilbert, who wrote "Eat, Pray, Love," described it, she described it wonderfully. I actually assign this to clients to read about being in - she was going through a divorce, so it's a different kind of grief, I guess, but saying that she felt like she was in a bottomless pit.
And she really resisted taking medication. I mean, she finally took something, and she said really all it did was give me a bottom to the pit, you know, and so then she could kind of reach out - or reach up and start clawing her way out of the pit.
And I think that's a really great description of how an antidepressant will work. It's not going to make your life happy and sunny, and everything's fine.
LUDDEN: You're not going to stop grieving.
COOK: No, not at all. And if you do, then something's wrong.
MILLER: I'm sorry. You know, I would just echo exactly what Ms. Cook was saying about that. Of course, as a psychiatrist, people do sometimes ask for medication, you know.
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MILLER: But that's probably more a function of where we sit. But many people who take an antidepressant - and again, I certainly understand that one of the goals here is to try to understand the difference between grief and depression, and we're both kind of tip-toeing around that subject because we...
LUDDEN: You're not giving us a checklist.
(SOUNDBITE OF LAUGHTER)
MILLER: Right, right. Well, you know, the checklists are very limited. And I prefer to think about problem lists. And, you know, sometimes the crying and the feeling stuck and the not functioning becomes intolerable to the person, and at that point, either through psychotherapy using a variety of techniques, trying to understand what might be at the root of being stuck, or looking at the symptoms and saying, you know, look, we can give you some relief or try to give you some relief with this or that.
And many people who opt for the medication do say this, that it puts a floor under them. They don't feel like a different person. It's simply easier to take care of the business of life and to become re-engaged. And that, of course, is the ultimately goal. I think ultimately, people do better in their lives when they are able to engage, and, you know, one of the models is that, you know, the work of grief is to try to, you know, work through or manage the giving-up of the person who's lost and to be able to reconnect to other people and other experiences in your life.
And, you know, and sometimes the medication can provide a bridge. Now there may be some people who before the loss may have suffered depression, which never came to light before.
LUDDEN: So maybe it's a trigger.
MILLER: So right, or it's a trigger, or the death has become a kind of an opportunity to get help that never was obtained before. So that's the reason that it's difficult to kind of go with a checklist and find exactly the dividing line between grief and depression because ultimately, I imagine Ms. Cook will agree with me, that we're in the business of trying to help people solve problems rather than give them a label.
Then the labels can sometimes help us organize the help, but they don't answer important questions.
LUDDEN: Let's get another caller on the line here. Mara(ph) is in Chico, California. Welcome to TALK OF THE NATION.
MARA: Oh, thank you. I'm a clinical psychologist. I've been in a private practice for about 10 years, and I experienced my own clinical depression when I was much younger and did take antidepressants at that time and found them to be very helpful.
And then I lost my mother almost 10 years ago, and I never, ever considered taking antidepressants during that time because subjectively it felt completely different. From the outside it might have looked the same. I was sort of catatonic. I couldn't speak. I sat on the couch and watched ridiculous movies over and over and over again.
But I didn't want to anesthetize or dull my senses. I wanted to be able to really cry and wail and grieve. And I knew that - and that hit me quite hard so that at about three years - oh, this is another important point, actually. The only relief I got was in my work, when I was engaging with other people. So with my own patients I felt a great deal of relief.
When I was depressed, the opposite was true. I found that it's very hard to be really present with my patients, with the - in those three, four years which were the hardest with the grief, I found that that was - you know, we were talking about the stuff that really matters and I'm really thoroughly engaging with them.
And this one last thing I will say is that everybody's process is different. I'm working with a woman now whose husband died two years ago, and her family wanted her to go on antidepressants. After about nine months, her doctor put her on antidepressants. She really hated it because she couldn't feel anything, so she took the stuff off. And she's going through her process as she goes through her process; it's a very individual thing, and I feel sort of - I feel kind of - that I have a little bit of an advantage, just as your - one of your experts there.
LUDDEN: All right. Well, thanks so much for the call, Mara.
MARA: You're welcome.
MILLER: You know - sorry.
LUDDEN: Oh, go right ahead, Dr. Miller.
MILLER: Ridiculous movies, by the way, I think, are an excellent treatment for all kinds of problems.
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MILLER: You know, the caller reminds me - not reminds me, because I never forget it. My father passed away about 10 years ago. He died of prostate cancer after about 15 years. And with several months to go, we kind of expected it, so it - but you know, when you expect it, it's still painful.
And then a few years after that, my younger sister - I got a call one August morning from my brother to tell me - this was a sister who was a dancer and a yoga instructor and the healthiest person in our family. And I got a call from my brother saying that she had died. And it was completely unexpected and a total and utter shock.
And those are very different kinds of experiences to have and exquisitely painful each in their own way. That just underscores, you know, what the caller was saying about how every loss is different, and everybody's path through it is different.
LUDDEN: We have a phone - an email from Vicky(ph), who writes that she works in hospice bereavement and has encountered this helpful guideline in some of the literature she's read: When a person is grieving, they have ups and downs and they're still able to experience moments of joy. When a person is depressed, there's a heaviness with very little variation and an inability to enjoy anything.
Does that ring true, Tammy Blackard Cook?
COOK: Yeah. Definitely. I like those last two descriptions, the caller and then this. I think – I think I read this in one of the Arthur Kleinman articles, but he was talking about how, you know, initially - and I was trying to say this before - there isn't a whole lot of places to find joy, initially, after a loss. But it seems - you know, obviously, you hear time heals all things, and it does.
And around six months it seems like there starts to be moments of joy, you know, and it just sort of builds from there. And I like that description, to distinguish between, you know, someone who is truly depressed versus someone who is going through the natural process of grieving.
LUDDEN: All right.
COOK: Can I say one other thing I was just thinking about in case it's helpful to people?
LUDDEN: Sure thing. Let me just say one thing quickly first.
LUDDEN: You're listening to TALK OF THE NATION from NPR News. Go right ahead.
COOK: One thing that strikes me is that, you know, a lot of times folks who come in to see us, it's not only that they're grieving and that they feel really, really sad and, you know, lonely and just all sort of - all sorts of things, but you know, they're also struggling with, you know, what's wrong with me?
So a lot of times, someone will come in, and maybe they're struggling with grief, but they don't come in until, you know, a few months down the road, and they come in because folks are tired - well, they will say, you know, I think my friends are tired of listening to me. You know, everybody moves on with your life, or moves on with their life, but your loss is still very, you know, depressing(ph) all the time for you, especially in that first year.
And so sometimes they come to therapy because they want to talk to somebody that they won't feel like they're burdening. And that question of what's wrong with me, you know, why do I still feel this way, sometimes talk therapy can be, you know, so healing because what we do is sort of say nothing. You know, we sort of create a safe place to say this is normal. We sort of normalize what they're feeling and, you know, give them some education around grief, because we don't like to feel bad.
LUDDEN: Let's get one more call in here. Cathy in Portland, Oregon, go right ahead.
CATHY: Yeah. Hi. Gosh, what a poignant topic for me these days. My baby died one year ago when I was eight months pregnant.
LUDDEN: Oh, I'm so sorry.
CATHY: And - thanks. When I was discharged from the hospital, they immediately gave me a prescription for an antidepressant, which I was really shocked by, but I never took. I thought, you know, I want to feel everything. I want to go through this process. I know this is horrible, but I just need to - I need to feel what's going on. And it's been a struggle. This past year has been really, really hard.
But I think - I finally went on antidepressants last month because it was getting to the point where I didn't even want to talk to anybody. I didn't want to - like the speaker said, I didn't want to burden anybody with my problems. I am - I think my friends were burnt out on hearing me. People kind of expected me to go on as normal, and I just really couldn't function. And, you know, there might have been a bit of undiagnosed depression before my loss. I don't know. It certainly runs in my family.
So I must say that I think it's a very individual choice. I mean, my counselor wasn't completely neutral about me going on them. You know, she said if it – she feels like it would help me. And my primary care physician said, OK, let's have you take them for six months and see how you feel after six months. And, you know, I think I'm on a - I don't know. I think I'm on a better course these days.
LUDDEN: All right. Cathy, well, thank you so much for the phone call.
CATHY: Thank you for listening.
LUDDEN: And I think we're going to have to leave it there. But this has been interesting and helpful. Our guests have been Tammy Blackard Cook, a therapist for Aspire Group based in Raleigh, North Carolina. She joined us from member station WUNC in Durham. And Dr. Michael Craig Miller is a psychiatrist who's editor-in-chief of the Harvard Mental Health Letter. He joined us from member station WBUR in Boston. Thanks so much to both of you.
MILLER: Thank you for having me.
COOK: Thank you.
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