Friday, February 17, 2012

Is Bereavement Part of Depression? And What the Hell is Depression, Anyway?

Willa Goodfellow’s latest Prozac Monologues piece raises the very important discussion about how bereavement fits (or not) into depression. Ronald Pies, one of the two principal figures behind the proposed DSM-5 “bereavement exclusion” to the depression diagnosis, has left a comment.

The discussion is framed in such a way that the nominal topic - bereavement - unlocks the key to the real issue, namely can any two people actually agree on what depression is all about? What about depression-like behavior?

Some background: The DSM-IV expressly rules out the depression diagnosis if the symptoms are attributable to bereavement for a period of two months or less. The DSM-5, due out in 2013, would drop this exclusion. This has created the mistaken notion that the DSM-5 is proposing to turn bereavement into a psychiatric illness. Allen Frances, who oversaw the DSM-IV, recently told the NY Times that “the revisions will medicalize normality.”

Let’s turn to what the DSM-5 is actually proposing. In the updated depression diagnosis, the symptom checklist would stay the same. In the fine print below, this gets the axe:

“The symptoms are not better accounted for by Bereavement ...”

Willa’s post sees this as the last piece in restoring the complete depression diagnosis. She points out that the DSMs I and II attempted to separate out depressions they saw as situational (exogenous) from those they saw as biological (endogenous). The DSM-III abolished this distinction, essentially viewing depression as a depression, but left in bereavement as an exception. The DSM-IV continued with this.

Willa asks us to view depression as something that happens when life throws too much at us, a point of view backed by some very impressive brain science. Some of us may be genetically resilient, but others (namely, us) prove highly vulnerable, owing to a hyperactive stress response. Says Willa:

What difference does it make whether the one damn thing too many is loss of a job or loss of a loved one?  It's still one damn thing too many.  And doctors need to take time to figure out what is going on with the person sitting in the office on her last nerve, not say, “There, there. You'll feel better in a couple months.”

As Dr Pies’ says in his comment:

[If] it looks like a duck, walks like a duck, and quacks like a duck, it's likely to be a duck, until proved otherwise. That is: if a patient shows up in the doctor's office meeting the full symptom and duration criteria for Major Depressive Disorder(MDD); but happens to have lost a loved one within the past two months, we should not withhold the diagnosis of MDD, simply because it occurs in the context of bereavement.

Are we clear on this? Good. Now let’s muddy it up. In an article on my website, Placing Depression in Context, I too observe the old clinical vs situational distinction, with reference to the DSMs I and II, and like Willa I view the distinction as naive and unscientific. But, nevertheless, I also see merit in bringing back some of the old reasoning. As I put it:

The endogenous-exogenous distinction does encourage us to examine where our depression might be coming from. If your marriage is falling apart, for instance, or your situation at work is going badly, it is obviously worth exploring this association. Sort of like investigating whether a person with a pulmonary disorder is working in an asbestos mine. For some crazy reason, the "modern" DSM-III of 1980 and its successors didn't think this was important.

I also looked at normal vs abnormal. In other words, are some of our depressions a normal reaction to an abnormal situation? Aren’t we supposed to feel depressed when we have lost a loved one? Moreover, if life is getting to be too much for us, our depressions may be telling us that we may need to make an immediate course correction. From my article:

This is straight out of evolutionary psychology. Depression has been called the end of denial. The rose-colored glasses come off. Reality takes over. Maybe instead of banging your head against the same wall - again and again and again - you need to cut loose destructive friends, bail out of a bad relationship, rethink that toxic work environment.

Listen to your depression. It may be an unwelcome guest in your brain, but it is definitely telling you something.

But my article also describes a situational depression I found myself in back in 2004, one that very easily could have led to a clinical depression. I simply did not have the luxury of leaving things to chance, not with my vulnerable brain. I immediately changed my routines and found a new project to work on.

In other words, I was feeling depressed. I needed to act right now.

This is precisely Willa’s point. Prior to reading her piece, I was on the side of not changing the bereavement exclusion. Now I’m teetering the other way. But this is because Willa’s piece challenged me to rethink depression, not bereavement. Depression is never what we think we think it is. Something to think about ....


Willa Goodfellow said...

Thanks, John. Can a blogger get higher praise than "...'s piece caused me to rethink..."?

You know I am no fan of the DSM V, within the larger context of knowing that the book will one day be an historical artifact of our unknowing, and the sooner the better. So it's easy to knee-jerk just about anything in it. The reason I have gotten off the knee-jerk bandwagon and am blogging about the bereavement exclusion is that Dr. Pies caused ME to rethink.

A question I ask in almost any post on the DSM revision is, "What is at stake?" For Pies and Zisook, at stake is whether care providers will take the time to listen to their patients who happen to have recently lost a loved one, to discern what is normal grief, following a normal course, and what is normal grief on top of a real mood disorder. They are concerned about patient care. They are NOT pushing pills. For both reasons, they deserve a careful hearing.

Thanks for extending it to them through me.

Anonymous said...

Sometimes death triggers depression. Sometimes mania. Sometimes psychosis. Sometimes increased obsessions and/or compulsions. etc.

I think a lot of people don't realize how people who have psychiatric issues react to life events. It can get pretty extreme. On one hand, I see their concern over the bereavement. For an inattentive or untrained doctor/nurse/physician assistant, those existential thoughts of, "What if I died? Does my life mean anything? Why was I put on this earth? Or am I actually the result of millions of years of randomness? This sucks!" can look like suicide ideation.

That is an unfortunate part of the DSM - the fact that it doesn't address what is actually more-or-less normal behavior, or even what "abnormal" behavior truly looks like. If it did either or both of those things, we probably wouldn't have nearly all of the issues with outcry on making everything psychopathology. Of course outlining those things comes with it's own host of issues, but it would be a start.

John McManamy said...

Hey, WIlla. I love people who make me rethink. :)

John McManamy said...

Hey, Anonymous. Totally agree. We only see symptom lists. We have no sense of a continuum of behavior. The personality disorders section of the DSM-5 makes a good faith effort at this, but the revisions to the revisions indicate just how difficult this is.

Please keep posting ...