After Bereavement, Is It “Normal Grief” or Major Depression?

The capacity to be consoled is a consequential distinction between grief and depression.-Kay Jamison, PhD, Nothing Was the Same

The relationship between grief and depression following recent bereavement has turned into one of the most contentious debates in psychiatry-and recently made front-page news in The New York Times.¹ Much of the controversy has focused on whether the so-called bereavement exclusion (BE) in DSM-IV should be eliminated, as some have proposed, in DSM-5. My colleagues and I have discussed this in several different venues, and have argued that there is no convincing scientific or clinical basis for retaining the BE.

In contrast, several prominent clinicians and scholars have argued forcefully for retaining the BE [see references below]. The debates have sometimes shed more heat than light, with one group arguing that the BE confuses clinicians and interferes with the diagnosis and treatment of potentially serious depression (my position) and the other group insisting that eliminating the BE will “medicalize normal grief” and lead to overprescription of antidepressants. (For those who want to delve into the debate, please see the collegial exchange Dr Sidney Zisook and I had with Dr Michael B. First.²)

In the meantime, the average clinician may be wondering, “What am I supposed to do with my bereaved patients while the so-called experts are battling it out? How do I distinguish a normal grief reaction, after a loss, from a major depressive episode?”

As a small step toward addressing this conundrum, I have developed an assessment tool that I call the Post-Bereavement Phenomenology Inventory (PBPI). It is based on the premise that the DSM symptom checklists simply do not permit an in-depth understanding of the different “world views” represented by ordinary (“productive”) grief and major depression.^3-5 Thus, the term “phenomenology” is used in the philosophical sense, in reference to the subjective experience of the patient-in effect, the structure and contents of the patient’s mental life.⁶

The PBPI represents neither a categorical nor a dimensional model of psychiatric evaluation; rather, it is an example of “prototype matching,” an approach that has shown promise in the diagnosis of bipolar disorder.^7,8 Although the PBPI is aimed primarily at assessing response to bereavement (the death of a loved one), it is my hope that it will also be of use after any major loss, such as divorce, job loss, or the break-up of an intimate relationship.

First, though, some caveats about the PBPI:
1. I offer this preliminary screening instrument without any claim that it has been validated in clinical studies, that it replaces a conventional “DSM” approach to diagnosis, or that it may be used in forensic assessments.
2. The PBPI is not intended as a substitute for a full psychiatric evaluation, including the use of validated screening instruments, such as the Beck Depression Inventory or other depression rating scales.
3. The PBPI is expected to be most useful when the results are combined with more empirical clinical findings in major depression, such as the absence or presence of early morning awakening, pronounced weight loss, visible psychomotor agitation or retardation, and diurnal mood variation.
4. The interpretation of patients’ responses to the PBPI has not yet been quantified, and there is as yet no “scoring system” for the results. Eventually, the items on the PBPI may be converted to a 4- or 5-point Likert-type scale.
5. The PBPI is not directly “translatable” into a DSM or ICD diagnosis; rather, it is intended to raise (or lower) the clinician’s index of suspicion that a bereaved patient may be experiencing a major depressive episode.

I am hoping that the PBPI will serve a heuristic purpose, in stimulating research on post-bereavement grief and depression. Indeed, the PBPI lends itself to many testable hypotheses and empirically falsifiable predictions. For example, I would hypothesize that patients who show a prominently “left-sided” profile of responses are more likely to represent cases of MDD, as determined by a complete diagnostic evaluation.

Further, I would hypothesize that patients with a strong left-sided profile would prove to be at a relatively higher risk for suicide, psychiatric hospitalization, and social-vocational impairment than patients with a prominent right-sided profile. In contrast, I would predict that those with a prominent right-sided profile would usually prove to be experiencing ordinary, or “productive,” grief in response to a recent major loss.

On the basis of the premise that grief and major depression are distinct constructs (albeit with some overlapping symptoms⁵), I would expect that most bereaved patients will produce something close to an “en bloc” response profile; ie, either most of the left-sided or most of the right-sided responses will be checked off. However, human emotional responses are notoriously prone to defying our constructs!

It is certainly possible that some patients will produce a “mixed,” or “left/right,” response pattern. It is not clear what condition this would represent, although in theory, patients who are experiencing “complicated grief”⁵ (sometimes called “pathological grief”) might produce such variegated responses. This is a question that will need to be settled with careful, empirical research.

It also seems plausible that a variety of biological, psychological, and social variables might cause a shift to the left or to the right, if the same patient were to complete the PBPI several times, over a period of weeks or months. For example, a bereaved person with several depressive symptoms who receives supportive counseling might show a shift to the right (toward ordinary, or productive, grief) in the course of grief-centered therapy.

Conversely, a bereaved patient whose grieving process is somehow thwarted or who is overwhelmed by a supervening major depressive episode might show a “shift to the left” when he is given serial PBPIs. Thus, sequential PBPIs might prove useful in the ongoing assessment of bereaved patients. From the standpoint of clinical management, however, clinicians should assume that left-sided responses “trump” right-sided ones. For example, any patient who checks off Item 8 (“persistent thoughts or impulses about ending my life”) will require immediate and thorough clinical evaluation, regardless of whether he or she has checked off several items on the right.

Similarly, a pattern of “5,9,10” checked off on the left-suggesting feelings of worthlessness, anhedonia, and psychomotor retardation-ought to serve as a “red flag” for the clinician. A patient with a “left 5,9,10” pattern merits careful evaluation to rule out an MDD-even if he checks several responses on the right.

Clearly, the particular patterns of responses and their interpretation will require careful longitudinal studies of post-bereavement grief and depression. Ultimately, I would like to see these two profiles of responses correlated with such indices as number of psychiatric hospitalizations; frequency of suicide attempts; impairment in vocational function; and biomarkers of major depression, such as neuroendocrine and inflammatory responses.

Hence, I welcome feedback from clinicians who might wish to use the PBPI as part of a research study of post-bereavement grief or depression, and I place no restrictions on its professional use. (However, it is not intended as a “self-screening” instrument, and those experiencing pronounced depressive symptoms should, as always, be guided by a thorough professional evaluation.)

It is my hope that the PBPI may point the clinician toward the need for further clinical assessment-and will perhaps provide a deeper understanding of the bereaved patient’s “inner world” than that obtained from symptom checklists.

Acknowledgment-I would like to thank Sidney Zisook, MD, and M. Katherine Shear, MD, for their helpful comments on an earlier draft of this scale, and for their seminal contributions to this area of research.

[Note: For a pdf of the below PBPI, click here.]

The Post-Bereavement Phenomenology Inventory (PBPI)

Instructions to patient: People who have experienced a recent, major loss react in a variety of ways. There are no “right” or “wrong” responses to this questionnaire. After each numbered item, please check the sentence (either in the left or right column) that better describes how you have been feeling, thinking, or behaving for the past 1 to 2 months. Please check only one box for each numbered item:

Which fits you better:

The sentence on the left?     Or . . .

The sentence on the right?

1.

I am filled with despair nearly all the time, and I almost always feel hopeless about the future.

I feel sadness a lot of the time, but I believe that eventually, things will get better.

2.

My sadness or depressed mood is nearly constant, and it isn’t improved by any positive events, activities, or people.

My sadness or depressed mood usually comes in “waves” or “pangs,” and there are events, activities, or people who help me feel better.

3.

When I am reminded of my loss (of a loved one, friend, job, etc), I feel nothing but pain, bitterness, or bad memories.

When I am reminded of my loss (of a loved one, friend, job, etc), I often feel intense grief or have painful memories, but sometimes I have good thoughts and pleasant memories.

4.

I will probably never get back to feeling like my “old self” again.

Things are really tough now, but I’m hopeful that with time I will feel more like my “old self.”

5.

I feel like a worthless person who has done mostly bad things in life, and let my friends, family, and loved ones down.

I feel like I’m basically a good person and that, in general, I have done my best for my friends, family, and loved ones.

6.

All I can think about lately is myself and how miserable I feel; I hardly think about friends, family, or loved ones, except to blame myself for some failing.

Even though I’m less social and outgoing since my loss, I still think a lot about friends, family, and loved ones, often with good feelings about them.

7.

When friends or family call or visit and try to cheer me up, I don’t feel anything or I may feel even worse.

When friends or family call or visit and try to cheer me up, I usually “perk up” for a while and enjoy the social contact.

8.

I often have persistent thoughts or impulses about ending my life, and I often think I’d be better off dead.

I sometimes feel like a part of me has been lost and I wish I could be reunited with the person or part of my life I am missing, but I still think life is worth living.

9.

Almost nothing that I used to like doing (reading, listening to music, sports, hobbies, etc) is of any comfort or consolation to me anymore.

The things that I have always liked doing (reading, listening to music, sports, hobbies, etc) give me some comfort and consolation, at least temporarily.

10.

I feel “slowed down” inside, like my body and mind are stuck or frozen, and like time itself is standing still.

My concentration isn’t as good as usual, but my body and mind aren’t slowed down, and time passes in the usual way.

Source: Ronald W. Pies, MD; 2012.

References:

References1. Carey B. Grief could join list of disorders. New York Times. January 24, 2012. http://www.nytimes.com/2012/01/25/health/depressions-criteria-may-be-changed-to-include-grieving.html?ref=benedictcarey. Accessed February 17, 2012.
2. First MB, Pies RW, Zisook S. Depression or bereavement? defining the distinction. Medscape Psychiatry. April 8, 2011. http://www.medscape.com/viewarticle/740333. Accessed February 17, 2012.
3. Pies R. The anatomy of sorrow: a spiritual, phenomenological, and neurological perspective. Philos Ethics Humanit Med. 2008;3:17.
4. Pies R. The two worlds of grief and depression. http://psychcentral.com/blog/archives/2011/02/23/the-two-worlds-of-grief-and-depression. Accessed January 27, 2012.
5. Zisook S, Shear K. Grief and bereavement: what psychiatrists need to know. World Psychiatry. 2009;8:67-74.
6. Schwartz MA, Wiggins O. Science, humanism, and the nature of medical practice: a phenomenological view. Perspect Biol Med. 1985;28:331-366.
7. Zimmerman M, Galione JN, Ruggero CJ, et al. A different approach toward screening for bipolar disorder: the prototype matching method. Compr Psychiatry. 2010;51:340-346.
8. Ghaemi, SN, Miller CJ, Berv DA, et al. Sensitivity and specificity of a new bipolar spectrum diagnostic scale. J Affect Disord. 2005;84:273-77. http://dx.doi.org/10.1016/S0165-0327(03)00196-4.

For further reading

• Bonanno GA, Wortman CB, Lehman DR, et al: Resilience to loss and chronic grief: a prospective study from preloss to 18 months postloss. J Pers Soc Psychol. 2002;83:1150-1164.

• Clayton PJ. Bereavement and depression. J Clin Psychiatry. 1990;51(suppl):34-38.

• Frances A. Good grief. New York Times. August 14, 2010. http://www.nytimes.com/2010/08/15/opinion/15frances.html. Accessed February 17, 2012.

• Ghaemi SN. Feeling and time: the phenomenology of mood disorders, depressive realism, and existential psychotherapy. Schizophr Bull. 2007;33:122-30. doi:10.1093/schbul/sbl061.

• Grohol JM. Will depression include normal grieving too? http://psychcentral.com/blog/archives/2012/01/25/will-depression-include-normal-grieving-too. Accessed February 17, 2012.

• Jamison KR. Nothing Was the Same. New York: Vintage Books; 2011.

• 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.

• Pies R. Once again: grief is not a disorder, but it may be accompanied by major depression. A Response to Dr John Grohol. Psychiatr Times. January 27, 2012. http://www.psychiatrictimes.com/blog/pies/content/article/10168/2023007.

• Pies R, Zisook S. Grief and depression redux: response to Dr Frances’s “compromise.” Psychiatr Times. September 28, 2010. http://www.psychiatrictimes.com/dsm-5/content/article/10168/1679026.

• Wakefield J. DSM-5: proposed changes to depressive disorders. Curr Med Res Opin. 2011 Dec 28. [Epub ahead of print]. http://www.ncbi.nlm.nih.gov/pubmed/22201516.

• Zisook S, Reynolds CF 3rd, Pies R, et al. Bereavement, complicated grief, and DSM, part 1: depression. J Clin Psychiatry. 2010;71:955-956.

• Zisook S, Simon NM, Reynolds CF 3rd, et al. Bereavement, complicated grief, and DSM, part 2: complicated grief. J Clin Psychiatry. 2010;71:1097-1098.