Sheila Wall, MD

Psychiatrists Should Not Fall Back on DSM

The Lure of the Context-Dependent Psychiatric Diagnosis

 Why do Drs Pies, Wakefield, and Horwitz feel that “blue” feelings after a major loss (such as death of a spouse) or, for that matter, any loss have to be either “grief” or “major depression”?

Frankly, if someone has come to me after a “significant” loss (but then, who can define significant?) and is suffering from the symptoms of major depression (even Freud said that the symptoms of grief/bereavement were the same as depression-he did not use the term “major depression” because it hadn’t been invented yet), you bet I would discuss with him or her the notion of using medication. This suggestion is appalling to some people who are grieving. I wouldn’t push the idea, unless the patient was frankly suicidal and had a plan. In that case, I would be seriously considering hospitalization-voluntary or involuntary.

Dr Pies presented the hypothetical case of a grieving patient whose symptoms were undiminished or perhaps even worse after a 1–week follow–up. However, this is not the fate of most patients who divulge their symptoms to their primary care doctor, who is scheduled to see patients approximately every 7.5 minutes. Because of the time constraints, the primary physician may well prescribe an antidepressant and antianxiety agent, if not a mood stabilizer, to cover all the bases and recommend that the patient see him or her in 6 months.

Talk of differentiating between “grief” and “major depression” is ludicrous in the “realpolitik” of the practicing psychiatrist, primary physician, or other “front–line” doctor. It is just another form of academic nattering.

I practiced psychoanalytic psychotherapy for 30 years. In this setting, I would introduce the subject of medication (probably not in the first session); I would talk to the patient and give him my phone number (answering service is okay-if you answer the calls); and I would see him frequently not only to gauge if his symptoms were worsening but also to talk about the aching grief of loss.

My point is that the patient’s feelings do not have to be classified as either grief or depression. Most of the time it is both. It is wrong to simply medicate a patient but offer him no forum in which to discuss his feelings. It is also wrong to provide a forum for that patient but not to provide medication.

Dr Wall is a board–certified psychiatrist. She was in private practice for 30 years and now serves as a psychiatric consultant for the Lebanon (Ohio) Center for the Severely Mentally Disabled. She also has an MFA in English literature and creative writing and is currently writing a novel.

I appreciate Dr Wall’s thoughtful letter, and-as an “academic” who also saw hundreds of severely depressed patients on the “front lines” for more than 25 years-I can assure Dr Wall that the issues at stake are not merely academic. They go to the heart of what psychiatrists consider “disorder” or “disease”; and of what kind of scientific evidence we require before we summarily exclude subgroups of patients with depression from the category of major depressive disorder. As I try to make clear in my commentary (“

Major Depression After Recent Loss Is Major Depression-Until Proved Otherwise

 December 2008, page 12), there are simply no credible data that would warrant exclusion of those who meet all severity and duration criteria for major depression, merely because they have experienced a significant loss in the preceding 2 months.

That said, I fully agree with Dr Wall that the concepts of “grief” and “major depression” are not mutually exclusive. A patient may be grieving a loss in such a “pathological” manner that the clinical picture becomes that of a severe major depressive episode. In 2 other articles I argue that dysphoric mood states exist along a continuum in which there is inevitably some “overlap” of conditions.

 On the vertical axis, one can plot increasing degrees of incapacity and impaired function; on the horizontal axis, one can discern increasing distortions in the experiential (phenomenological) realm. For example, in more severe depressive states, the person may experience profound self–loathing, a sense of complete isolation, a sense that time has “stopped,” and so on. Clearly, 

 criteria alone are not enough to capture these existential nuances.

I also agree with Dr Wall that if a patient presents after a significant loss and is demonstrating severe psychic and neurovegetative signs and symptoms of major depression, we should certainly discuss the option of medication

 and psychotherapy. (For most cases of severe depression, I would use a combined form of treatment.) Hospitalization should also be considered, particularly if the patient is at high risk for suicide-and it should make no difference whatsoever, in such cases, whether we can identify a recent “loss” in the patient’s history.

Dr Pies is professor of psychiatry and lecturer on bioethics and humanities at SUNY Upstate Medical University in Syracuse and clinical professor of psychiatry at Tufts University in Boston.

 Pies R. Depression or “proper sorrows”?-have physicians medicalized sadness? Prim Care Companion. 

 Pies R. The anatomy of sorrow: a spiritual, phenomenological, and neurological perspective. 

 Zisook S, Shuchter SR, Pedrelli P, et al. Bupropion sustained release for bereavement: results of an open trial. 

Articles

Why do Drs Pies, Wakefield, and Horwitz feel that “blue” feelings after a major loss (such as death of a spouse) or, for that matter, any loss have to be either “grief” or “major depression”?

Sheila Wall, MD

Articles

Depression or Major Loss, or Both?