I’d like to respond to Dr Cacciatore’s concerns and comments, as well as to some points raised by other readers. I also want to acknowledge the deep pain of those who have lost loved ones, and who have written in to this Web site.
I’d like to respond to Dr Cacciatore’s concerns and comments, as well as to some points raised by other readers. I also want to acknowledge the deep pain of those who have lost loved ones, and who have written in to this Web site. Your grief is not something to be judged or criticized or covered over-and nobody in my profession would argue otherwise.
Furthermore, I want to acknowledge the excellent work being done by Dr Cacciatore and the MISS Foundation, which provides support and counseling to families who are grieving the death of a child. We can all agree on the importance of helping such families through what is undoubtedly one of life’s most painful and anguishing experiences. As one useful Web site puts it1:
There is no more devastating loss than the death of a child. Losing a child is a disruption in the natural law and order of life. It is heartbreak like no other. Parental grief is different from other grief-it lasts longer and is more intense.
Most of the research on bereavement has been done in the context of the death of a spouse, which is also an experience of tremendous pain and anguish. Accordingly, most of what my colleagues and I have written regarding bereavement is based on studies of widows and widowers. These studies generally show that while many widows and widowers do show several symptoms of major depression shortly after bereavement, the majority do not meet full DSM criteria.2 For example, Zisook and Shuchter2 studied spousal bereavement in late life and found that about 24% of subjects met DSM-III-R criteria for major depression 2 months after bereavement. The percentages declined to about 14% at 25 months.
As Dr Karrie C. Hendrickson3 of the Yale School of Nursing has noted, parental grief after the death of a child is not nearly as well researched as spousal bereavement, and the existing literature provides conflicting data. I’m not aware of any studies of parental grief after the death of a child, using DSM criteria, within the first 2 months after the child’s death. But it would not surprise me if many or most recently bereaved parents met current DSM criteria for an MDD within the first few weeks of the child’s death. The question is, what would this mean? Would a high percentage of parents with MDD necessarily indicate that there is no cause for clinical concern, or no need for treatment? Would it not be “real” major depression?
It is often said that symptoms of major depression after bereavement (death of a loved one) are “perfectly normal”-but what does “normal” mean? Does it mean “frequent” or “occurs most of the time”? Does it mean “healthy,” “adaptive,” “not clinically important”-or what? For example, Dr Hendrickson’s review found evidence that bereaved parents are at higher risk for completed suicide than are members of the general population, particularly if the child is younger than 6 years at the time of death. Cases of parental suicide within days after the death of a child have been reported, even after the parent denied suicidal feelings or intentions to the doctor.4
Yes, to be sure, it is sometimes hard to tell severe grief from symptoms of major depression in the first few weeks after bereavement. But this does not justify the notion that MDD should be “excluded” as a diagnosis during the first few weeks after a family member’s death. Dr Cacciatore is quite right in raising a red flag over the 2-week duration issue. My colleagues and I have argued that 2 weeks is often too little time to make a confident diagnosis after any major loss-whether the death of a spouse, a divorce, or even a job loss.5
And yes, when the death of a child is involved-a tragedy that is almost unfathomable-I would expect even greater difficulty in predicting the “trajectory,” or course, of the bereaved parent’s depressive symptoms only 2 weeks after the death. These are all reasons to change the 2-week criterion for MDD, but none of this justifies keeping the bereavement exclusion in DSM-5. We must also greatly increase the training of all physicians and mental health clinicians, so that they can better distinguish grief from MDD.
To be clear: nobody wants to see doctors prescribe antidepressant medication when it isn’t needed or to “medicalize” ordinary grief. Unfortunately, definitive controlled studies have not been done, and virtually no studies have looked at bereaved individuals within 2 weeks of the death. But most of the available studies find no major differences in course, outcome, risk, or response to treatment when MDD symptoms occur in the context of bereavement, after another type of loss, or in the absence of any loss at all.6
Dr Kay Jamison, who lost her husband to cancer, eloquently describes the differences between major depression and the grief of bereavement. I recommend watching her video interview.7 In her book Nothing Was the Same, Dr Jamison comments that “the capacity to be consoled is a consequential distinction between grief and depression.” Indeed, this is one of the distinguishing features of ordinary grief that is not even mentioned in the DSMs.
It is one reason we need to move beyond symptom checklists in trying to understand the difference between grief and major depression. My colleagues and I have started to develop a questionnaire, the Post-Bereavement Phenomenology Inventory (PBPI), aimed at helping clinicians tell the difference.8
I hope Dr Cacciatore will join me and my colleagues in investigating the utility of the PBPI for her bereaved clientele. We certainly share the goal of respecting the need to grieve and supporting families and loved ones through the stages of bereavement. I believe all of us in the helping professions want to honor what Thomas a Kempis called, “the proper sorrows of the soul.”
Ronald Pies, MD
References1. Anastasi JM, ed. The Death of a Child, the Grief of the Parents: A Lifetime Journey. 3rd ed. Washington, DC: National Sudden and Unexpected Infant/Child Death and Pregnancy Loss Resource Center at Georgetown University; 2011. http://www.sidscenter.org/documents/SIDRC/LifetimeJourney.pdf2. Zisook S, Shuchter SR. Major depression associated with widowhood. Am J Geriatr Psychiatry. 1993;1:316-326.
3. Hendrickson KC. Morbidity, mortality, and parental grief: a review of the literature on the relationship between the death of a child and the subsequent health of parents. Palliat Support Care. 2009;7:109-119.
4. Davies DE. Parental suicide after the expected death of a child at home. BMJ. 2006;332:647-648.
5. Lamb K, Pies R, Zisook S. The bereavement exclusion for the diagnosis of major depression: to be, or not to be. Psychiatry (Edgmont). 2010;7:19-25.
6. Kendler KS, Myers J, Zisook S. Does bereavement-related major depression differ from major depression associated with other stressful life events? Am J Psychiatry. 2008;165:1449-1455.
7. Jamison KR. Big think interview with Kay Redfield Jamison. http://bigthink.com/ideas/16713. Accessed March 15, 2012.
8. Pies RW. After bereavement, is it “normal grief” or major depression? February 21, 2012. http://www.psychiatrictimes.com/blog/pies/content/article/10168/2035804. Accessed March 15, 2012.