The relationship between grief and depression

In Practice

November 28, 2011|By Dr. Suzanne Koven, Globe Correspondent

(DAN PAGE )

After 50 years of marriage, Mr. F. died, and Mrs. F. was heartbroken. No, that’s an understatement: She was devastated. For weeks she cried, couldn’t sleep, couldn’t eat. Activities she usually enjoyed, like going out for lunch and volunteering at the local library, held no appeal. A warm, witty woman with an outsized grin, Mrs. F. - a patient of mine - had always arrived in my office dressed in bright pink, lavender, or red. Long after her husband’s death, Mrs. F. still wore black and gray, and both her wit and her grin remained absent.

Though she’d never suffered from depression before, and had no family history of the disease, Mrs. F. now seemed to meet the criteria for major depression set out in the Diagnostic and Statistical Manual used to define mental illnesses. According to the DSM IV-TR current edition, people are said to be in a major depressive episode if, for a two-week period, they have at least five symptoms from a list of nine, including lethargy, slowed speech and movement, difficulty concentrating, and decreased interest in normally pleasurable activities. Mrs. F had eight of the symptoms - and for far longer than two weeks. But the fact that Mrs. F. was grieving ruled out major depression according to the DSM IV-TR, which excludes the bereaved from this diagnosis.

Still, I urged Mrs. F. to consider taking an antidepressant. I hated to see her suffer and I worried about her health. Depression increases the risk of heart disease, especially in people over age 65. Also, though Mrs. F. said she hadn’t considered harming herself (the only one of the nine symptoms she didn’t have), depressed older people who live alone commit suicide at higher rates than the general population.

But Mrs. F didn’t want antidepressants. She only wanted her husband back.

In my medical training, I learned that there are two distinct types of depression: major depression and situational (or reactive) depression. Major depression, I was taught, occurs for no apparent reason - its victims often have “nothing to be depressed about.’’ It results from an abnormality of brain chemistry, and responds best to drug therapy. In contrast, situational depression, my professors said, develops when someone suffers a loss or trauma. It’s treated with psychotherapy, not drugs.

I hadn’t been in practice long before I realized that this distinction is not really so clear. I had patients with major depression who were only partially restored to health by antidepressants and needed talk therapy to fully recover. And I saw people who’d never been seriously depressed before thrust into what seemed to be major depression by a personal loss - and whose mood improved with medication.