One telling symptom of the separate-worlds problem is how our modern diagnostic system handles low mood in the context of a death. In the official bible of diagnosis, the Diagnostic and Statistical Manual of Mental Disorders, depression within two months after a death is usually not depression. Instead depression right after a death would be considered under another category called "simple bereavement." In fact, of all the things that can befall a person, bereavement is the only life event that can potentially negate a diagnosis of depression. Why did the DSM framers separate bereavement from regular depression? They did because they conceived of bereavement as an essentially adaptive response, which did not fit with their concept of depression, which must represent a disease or maladaptive response.

Here are three reasons why we should return to a more unified view of bereavement and depression:

First, the clinical depressions that are due to a death appear to be indistinguishable from other depressions. For example, Jerome Wakefield and colleagues published an article in the Archives of General Psychiatry, the flagship journal of psychiatry, that analyzed a nationally representative sample of the United States, the National Comorbidity Survey (NCS), which contained 8098 persons aged 15 to 54 years. The authors went back and reexamined this vast data set, which included extensive psychiatric interviews of all 8098 participants. They were able to identify persons whose depression was triggered by a death and contrast them to persons whose depression was triggered by other sorts of losses, such as the loss of a job or the end of a marriage. In these national data, depression triggered by bereavement and depression triggered by other losses were astonishingly similar: the two depressions had similar symptom profiles and were similar on how long the symptoms lasted, whether or not the person attempted suicide, how much the symptoms interfered with life, and whether the person sought out mental health services for their difficulties. In sum, those people whose depression would have ordinarily been considered "simple bereavement," and thus excluded by the DSM bereavement exemption, had depressions that were in virtually every way similar to all other depressions. We now have data from other countries --including France, Lebanon, and Denmark- and everywhere that bereavement-related and non-bereavement related depressions have been compared, the data indicate that depression-is-depression.

Second, bereavement is a prototypic cue for depression. In general, depression has a relationship to events in the world, with almost 9 of 10 depressed people able to identify external events that in some way contributed to depression, and with more than half of depressed people reporting a severe stressful life event prior to the depression onset. Of course not all bad events are the same. Bad events have many themes --uncertainty, danger, humiliation, injustice, etc. When objective coders rate the themes raised by different life events, the theme that predicts depression most strongly is the theme of loss. While there are many important loss events including, loss of a job, marriage, or reputation, the ultimate loss event, hands down, is the loss of a significant other to death. Bereavement is prototypic of circumstances that give rise to depression.

Third, bereavement arouses behaviors that are similar to behaviors we see in "regular" depression, namely behaviors that are focused on a loss and ultimately on its restoration. When we think of funerals, gravestones, cemeteries, and all the special rituals that surround grieving a person, it's easy to forget that very different kinds of losses can drive similar core behaviors. For example, just like those who grieve a death, those who lose fortune (an all-too-common loss these days) pine for the lost object, and engage in counterfactuals about what might have been.

The same may be said for those who have depression after a romantic breakup, who are haunted by thoughts, images, and memories of their former lover and come to review and replay all of their behaviors about what they did and said before getting dumped. In other words, grieving behaviors are very typical in people who are depressed. Of course in many cases of depression, there are no obvious loss events. Sometimes the theme of loss is still there in more subtle ways. Take a young adult's depression that starts after he/she takes a practical first job after college; the depression might reflect the loss of a childhood career dream, even if this is not explicitly discussed. Because the circumstances of life are complex and changing, it is not always easy to understand the sources of our moods. Connections between a loss and symptoms may be hard to see. My hypothesis is that many people have an insight only later that they were grieving a loss during their depression.

 

Bereavement and depression should not be in separate worlds. The road to understanding depression runs through bereavement.

Reference

Wakefield, et al., (2007). Exclusion for major depression to other losses: Evidence from the National Comorbidity Survey. Archives of General Psychiatry, 433-440.

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If you've had an experience relevant to this post, I would be interested in hearing about it. Please email me at chartingthedepths@gmail.com