Clinical depression or “life sorrows”?

Clinical depression or “life sorrows”? Distinguishing between grief and depression in pastoral care 1

How does the pastoral counselor distinguish ordinary grief from clinical depression?

Ronald W. Pies, MD, is professor of psychiatry, lecturer on bioethics & humanities at SUNY Upstate Medical University, Syracuse, New York; and clinical professor of psychiatry, Tufts University School of Medicine, in Boston, Massachusetts, United States.

Cynthia M. A. Geppert MD, PhD, MPH, is professor of psychiatry and director of ethics education, University of New Mexico School of Medicine; and chief, consultation psychiatry & ethics, New Mexico Veterans Affairs Health Care System, Albuquerque, New Mexico, United States.

As psychiatrists, we are all too familiar with the suffering that accompanies clinical depression. But, as ethicists and writers on religious and spiritual matters, we are also concerned with the critical distinction between depression and ordinary grief, and we believe that this is a vitally important question worthy of the consideration of all ministers and counselors. How does the pastoral counselor distinguish ordinary grief—a normal and adaptive emotion that clergy are trained, and often best suited, to handle—from clinical depression, which often requires professional referral for psychological or, in some instances, psychiatric treatment?

The biblical phenomenology of grief

The distinction between clinical depression and ordinary grief seems as old as recorded history. In Psalm 38, the psalmist laments his sins. He tells us that “there is no soundness in my flesh . . . no health in my bones because of my sin. . . . My wounds grow foul and fester because of my foolishness, I am utterly bowed down and prostate; all the day I go about mourning. . . . I groan because of the tumult of my heart.”2 Psychiatrists today would likely recognize in this description clinical symptoms of major depression, such as psychomotor slowing (“utterly bowed down”) and a severely depressed mood. The psalmist’s sense of bodily decay and self-loathing are more suggestive of clinical depression than of grief, in which the sense of self-worth is usually intact.

In contrast to Psalm 38, the same King David—after the death of his beloved friend, Jonathan—is far from “bowed down and prostrate.” Rather, after a brief period of ritualized weeping and fasting, David is moved to write a passionately stirring dirge, known as “The Lament of the Bow” (2 Sam. 1:17–27), addressed to his lost friend. “How have the mighty fallen . . . I grieve for you, my brother Jonathan, you were most dear to me” (author’s translation). Here, there is no trace of the self-loathing and bodily decay found in Psalm 38. Rather, in David’s grief for the man described as “knit to his soul” (1 Sam. 18:1) we hear the plaintive note of yearning. Also note that David’s expression of grief recalls “the good times” of the lost relationship (“you were most dear to me”). As we will see, the ability to summon positive recollections of the deceased is one of the hallmarks of normal grief after bereavement and rarely seen in clinical depression.

The anatomy of grief and depression

Although the boundaries between ordinary grief and clinical depression are sometimes hard to discern, there are experiential or “phenomenological” features that help us distinguish these conditions. For example, when we experience everyday grief or sorrow, we generally feel—or at least, are capable of feeling—intimately connected with others. Healthy grief is directed outward toward a far-reaching recollection of the memories of the lost loved one. In this remembering process, the compassion and company of friends, family, and clergy often help the bereaved. Through shared experience, the memory of the deceased is “enlivened” and the spirit of the bereaved “strengthened.”

In contrast, when we experience severe depression, we typically feel outcast and alone. Sorrow, to use Martin Buber’s terms, is an “I-Thou” or relational experience; clinical depression, a morbid preoccupation with “me.” Indeed, William Styron describes depressed individuals as having “their minds turned agonizingly inward.”3 Severe depression consumes the self and forms a mental fortress that neither clergy nor caring loved ones can breach without clinical reinforcements.

One’s subjective sense of time also differs in grief and depression. When we experience everyday sorrow, we have the sense that, someday, this sorrow will end. As Psalm 30 tells us, “Weeping may last for the night, but joy returns in the morning” (v. 5, author’s translation). In contrast, severe depression envelops us with the sense that it will last forever. Dr. Nassir Ghaemi has called attention to the sense of temporal distortion in depression (i.e., the subjective feeling that time itself is slowed).4 Sorrow has the capacity to contain joy within it or, at least, to find solace within its own essence. Sorrow, in this sense, is dialectical: it generates an inward “conversation” between hopeful possibility and hopeless despair—especially in people of faith who are able to view the sorrow sub specie aeternitatis. Thus, when Martin Luther was confronted with the imminent death of his beloved daughter, Magdalena, he is said to have uttered these words to the girl as she lay dying in his arms: “Lena dear, my little daughter, thou wilt rise again and shine like a star—yea, as the sun! I am happy in the spirit, but in the flesh I am very sorrowful.”5

Moreover, there is an intentional dimension to grief and sorrow absent in clinical depression. In effect, we are overtaken or “invaded” by depression as a force outside ourselves, whereas we give ourselves over to sorrow. Thus, in his autobiographical account of depression, Andrew Solomon comments on “the terrible feeling of invasion that attends the depressive’s plight.”6

Finally, clinical depression is experienced as foreclosing the possibility of moving forward in life. In contrast, while grief and sorrow are often profoundly painful, they also provide opportunities for spiritual growth. This perspective is nicely elucidated by the psychotherapist and former monk Thomas Moore: “Sorrow removes your attention from the active life and focuses it on the things that matter most. When you are going through a period of extreme loss or pain, you reflect on the people who mean the most to you instead of on personal success; and the deep design of your life, instead of distracting gadgets and entertainments.”7

The usual course of bereavement-related grief

As Dr. Katherine Shear has observed, “The universality of grief is as incontrovertible as its uniqueness. Grief is an experience shared by all humanity. It is an instinctive response that we understand at an intuitive level. We naturally expect grief to progress over time, becoming reshaped and integrated as we make peace with the grim new reality. Still, we are often confused about what that transformation looks like and how long it should take.”8

Indeed, there is no one “correct” or predictable course for bereavement- related grief. As Dr. Sidney Zisook and Shear explain, many determinants are in play: “The intensity and duration of grief is highly variable, not only in the same individual over time or after different losses, but also in different people dealing with ostensibly similar losses. The intensity and duration is determined by multiple forces, including, among others: the individual’s preexisting personality, attachment style, genetic makeup and unique vulnerabilities; age and health; spirituality and cultural identity; supports and resources; the number of losses; [and] the nature of the relationship.”9

Gender and culture can also shape the visage of grief. Thus, while stereotypes must be avoided, men in our Western culture may eschew the emotional expression that women are socially “permitted” to display. Despite these many variables, some general statements regarding the usual course of grief (sometimes called “normal” or “uncomplicated” grief) do apply. In the early days and weeks following the death of a loved one, the bereaved typically experiences acute grief. This may often be an intensely painful period, during which the grieving person may experience frequent bouts of tearfulness; difficulty sleeping and concentrating; reduced appetite; and diminished desire to “socialize,” notwithstanding some receptivity to consolation from friends and family that is characteristically absent in depression. Typically, grief is experienced in “waves” or “pangs,” rather than the unremitting gloom of depression. Often mixed with grief are pleasant recollections of the deceased.

Not uncommonly, the recently bereaved person may hear the voice or see the image of the deceased, usually very fleetingly.10 Clergy can often help mental health practitioners recognize these visions as expected manifestations of acute grief rather than as symptoms of psychotic depression.

Many elements of acute grief may be mitigated by the comforting rituals of mourning, such as the seven days of “sitting shiva” in the Jewish faith. Conversely, social or cultural isolation may intensify acute grief. If the grieving and mourning process proceeds as expected, a subtle transition begins, usually within the first few months after bereavement—namely, the emergence of integrated grief. During this phase, the pain of loss is woven into the larger fabric of the bereaved person’s life. Integrated grief entails greater acceptance of the death, renewed interest and engagement in life, a pre- dominance of positive emotions when recalling the deceased, and a reduction in preoccupation with thoughts and memories of the deceased.11

This does not mean that the loss is ever “forgotten” or “put behind” the bereaved person. Nor should the grieving person be admonished to “get over it and move on.” Grief is not an experience so much as an unfolding process, and it may persist for years, or even a lifetime.

Pastoral counselors and chaplains can cooperate with mental health clinicians to help the bereaved see bereavement as a kind of transposed or transformed relationship with the deceased—one that may endure for many years. This is why the bereaved so often say, “He lives on in my memories,” which is a highly spiritual concept. For some bereaved persons, extended grieving may involve periodic visits to the deceased’s gravesite, where they may “speak” to the lost loved one, or participation in religious observances that honor the deceased and provide an opportunity to remember.12

Grief is not a “disorder” and requires no professional treatment. However, the grieving process is sometimes derailed or complicated in one way or another. Indeed, the term complicated grief (CG) is often applied when the transition from acute to integrated grief is disrupted or impaired. Clergy should be able to recognize CG because it may signal arrested progression and integration of grief, or presage the development of major depression—both of which may need and benefit from professional treatment, along with continued spiritual support. Though a full discussion of CG goes beyond the scope of this paper, Shear and others have described some characteristic features, including but not limited to the following:

• Continued difficulty accepting the death, extending beyond six months

• Persistent strong yearning for the deceased

• Anger and bitterness (e.g., over the circumstances of the death)

• Preoccupation with the deceased

• Excessive avoidance of any reminders of the deceased

• Futility about the value of ongoing life and relationships

• Impaired functioning and disability13

A portrait of major depression

The sorrowful and the severely depressed inhabit two quite different existential realms, though the two “universes” intersect in certain experiential aspects. Both the sorrowful and the depressed person, for example, will describe sadness and loss. The severely depressed person, however, endures a unique kind of soul-killing suffering, eloquently described by the writer William Styron: “Death was now a daily presence, blowing over me in cold gusts. Mysteriously and in ways that are totally remote from normal experience, the gray drizzle of horror induced by depression takes on the quality of physical pain. . . . [The] despair, owing to some evil trick played upon the sick brain by the inhabiting psyche, comes to resemble the diabolical discomfort of being imprisoned in a fiercely overheated room . . . [thus] it is entirely natural that the victim begins to think ceaselessly of oblivion. . . . In depression the faith in deliverance, in ultimate restoration, is absent.”14

As this description suggests, there are pronounced experiential differences between the grief of bereavement and clinical depression. For example, clergy and counselors should know the importance of recognizing that if the grieving person has a longing for death, this usually involves thoughts about “reunion” with loved ones that may provide some spiritual consolation. In contrast, the severely depressed patient’s mood is often accompanied by thoughts or plans of suicide and the sense that he or she “doesn’t deserve” to live.

Such suicidal ideation or plans— especially when accompanied by expressions of self-loathing and guilt—represent a true mental health emergency that requires timely referral to mental health practitioners. Unlike the normally grieving person, the severely depressed individual is usually too self-focused and emotionally isolated to appreciate the consolation of others or seek out and respond to pastoral comfort. In contrast, the grieving person usually maintains a strong emotional bond with friends, family, and, in some cases, clergy, and they often accept consolation from them. Indeed, psychologist Dr. Kay R. Jamison has observed that “the capacity to be consoled is a consequential distinction between grief and depression.”15

Sometimes, friends, family, or inexperienced clinicians may mistake ordinary grief for major depression. But, more commonly, signs of serious major depression are inappropriately dismissed as “normal” merely because they occur soon after the death of a loved one. This misperception sometimes takes the form of what one of us (Ronald Pies) has called “the fallacy of misplaced empathy”—the mistaken notion that if we can just understand how someone came to be depressed, we have established that the person’s mood is normal.16

Spiritual and secular counselors—for whom listening, compassion, and acceptance are virtues of habit and temperament—may be especially vulnerable to this well-intended but misplaced “normalization.” In the Judeo-Christian tradition, the bereaved have a special status of reverence and recusal from responsibility, which is often ritualized. Clergy and therapists alike may fi d it uncomfortable to opine that the bereaved is “depressed”—but in doing so, they can help reduce the stigma of the diagnosis, which often prevents religious persons from seeking mental health treatment.

Because grief and depression are separate conditions, it follows that the two may coexist, particularly after bereavement, and may benefit most from the collaborative care of clergy and mental health practitioners. In fact, bereavement—far from “immunizing” the person against major depression— is actually a common precipitant of the disorder.17 This makes it all the more important for chaplains and pastoral counselors to recognize and respond appropriately to major depression. People of faith frequently have far more trust in their clergy than in a clinician; indeed, a priest, minister, or rabbi may be the only person able to persuade the bereaved to seek mental health attention. If major depression is suspected, referral to a mental health professional is warranted. In milder cases, psychotherapy alone often suffices as treatment; for more severe major depressive episodes, medication may be required. Even after referral, however, pastoral care is still salutary, especially for the resolution of grief and the spiritual support of the bereaved. We encourage clergy and mental health practitioners, with the patient’s consent, to work collaboratively in the service of holistic healing—thus addressing the mental, physical, and spiritual dimensions of the person.

Some of the principal differences between grief and major depression are summarized in the table below:

Grief

Major Depressive Disorder (MDD)

Definition/concept

The range of thoughts, feelings, and behaviors in response to death of a loved one, close friend, or family member; or to other major loss.  After bereavement, grief is often accompanied by culturally based rituals of mourning.

Psychiatric illness in which distress and suffering are marked and normal function is significantly impaired; the most severe forms of MDD are “melancholic” and psychotic major depression.

In acute form, profound sense of loss, intense sadness, longing, yearning for the deceased; tearfulness; feeling of “aching void” early in grief process. Anguish, anger, anxiety, loneliness are sometimes present, especially in initial period after loss.

Usually, profound and pervasive sense of despair, hopelessness, helplessness, gloom, nihilism, “time standing still.” Markedly diminished pleasure in nearly all activities.

Variability of mood, feelings

Changes from hour to hour and day to day; sadness, longing, tearfulness often come in “waves” or pangs in response to reminder (external or internal) of deceased; usually interspersed with periods of positive emotions, happy recollections and memories of deceased. Bereaved is usually “consolable” by friends, family

Very little change from day to day; positive feelings diminished or absent (inability to experience positive emotions is hallmark of major depression); markedly depressed mood most days of the week for > 2 weeks. Rarely consolable by friends, family.

Sleep, appetite

Bereaved may have trouble falling asleep because thoughts of deceased are triggered, (e.g., if bed previously shared with deceased, or by rumination re: troubling aspects of the death).

 Awakenings may occur, but sleep physiology usually normal.

 Appetite and usual scheduling of meals may be disrupted by heightened emotionality related to reminders of the deceased. Weight loss usually minimal

Early morning awakening (e.g., 4:00 a.m.) is classic finding. (Rarely: excessive sleep/hypersomnia).

 Loss of appetite often leads to significant weight loss. (Rarely: weight gain in “atypical” depression). Anorexia often severe, with substantial weight loss (>10 lbs).

Energy, psychomotor change

Intense emotions may disrupt sleep and interrupt the bereaved person’s usual rhythm of daily life. In some cultures, dramatic expressions of grief resemble psychomotor agitation but are more ritualized.

Often marked slowing of mental processes and decreased energy; markedly decreased or increased motor activity (e.g., speech volume and output greatly diminished; marked agitation, hand-wringing, twisting hair, etc.).

Reality Testing

The recently bereaved may transiently appear “lost” or confused; may briefly hear voice or see image of deceased; but is in touch with other aspects of reality (not delusional).

Severe MDD with psychosis may show delusions of bodily decay, “rotting away”, being “punished by God”; may experience derogatory auditory hallucinations.

Self-Image

Self-esteem largely preserved though often with feelings of identity and/or role confusion; guilt or remorse is common but usually fleeting and focused on the deceased (e.g., “If only I had said or done . . .”).

Self-loathing, feelings of worthlessness, being an “unforgiveable” person or “terrible sinner”; profound, corrosive guilt without evident reason.

Thoughts of death, dying

Sometimes, feelings of not wanting to live without the deceased; or fantasies of “reuniting” with deceased; usually without suicidal plans or intent.

Suicidal ideation and plans are common; person may feel “I don’t deserve to live.”

Social/Vocational function

Early in bereavement, socializing may feel difficult, but bereaved usually desires, enjoys company of friends and family, at times. Feelings of disconnection from others may occur, but deeper emotional bonds usually preserved. Vocational function usually maintained, but person often distracted at work, preoccupied by loss.

Social withdrawal often profound; person feels deeply estranged from others; may isolate self in room; refuse any visitors.

Vocational function usually significantly impaired, often with missed work days.

Course/Outcome

Typically, acute grief evolves over time, though progression is erratic; no “set” duration for acute     grief. Integrated grief often lifelong, but grief is transformed such that bereaved person able to re-engage with life, with “bittersweet” acceptance of loss.

Variable duration, often lasting many months and sometimes years, if not adequately treated. Suicide is outcome in around 4 percent of those with major depression.

Treatment Support, guidance, education, may be helpful, but grief is not a mental disorder and needs no professional “treatment.” Often requires professional treatment, with either psychotherapy or medication, or both.

 

Conclusion

Grief and major depression occupy different realms of human experience, even though they share some features (such as sadness, tearfulness, insomnia, etc.) and may coexist in the same individual. This coexistence may complicate diagnosis and treatment, particularly if the counselor or clinician is unfamiliar with the substantial differ- ences between grief and depression. In the acute post-bereavement period, these discriminations are especially important because they have a direct bearing on disposition and treatment. When counseling the recently bereaved person, the pastoral counselor—as a healing professional—should recognize and respond to the warning signs of a major depressive episode, which requires professional treatment.

References: 

1 The authors wish to thank Dr. Robert Daly, Dr. Sidney Zisook, and Dr. M. Katherine Shear for their helpful references or comments for this article.

2 Unless otherwise noted, all scriptures quoted in this article are from the Revised Standard Version of the Bible.

3 William Styron, Darkness Visible: A Memoir of Madness (New York: Vintage, 1992), 47.

4 S. Nassir Ghaemi,“Feeling and Time: The Phenomenology of Mood Disorders, Depressive Realism, and Existential Psychotherapy,” Schizophrenia Bulletin 33 (2007): 122–130.

5 Murat Halstead, Story of Opportunity or Character Building (Whitefish, MT: Kessinger Publishing, 2003), 582.

6 Andrew Solomon, The Noonday Demon: An Atlas of Depression (New York: Touchstone, 2002), 293.

7 Thomas Moore, DarkNights of the Soul: A Guide to Finding YourWay Through Life’sOrdeals (New York: Gotham, 2005), 211.

8 Katherine Shear,“Complicated Grief: Reframing the Way We Think About Love and Loss,”Pacific Standard, June 16, 2014, www. psmag.com/navigation/health-and-behavior/complicated-grief- reframinway-think-love-loss-83511/.

9 Sidney Zisook and Katherine Shear,“Grief and Bereavement: What Psychiatrists Need to Know,”World Psychiatr8, no. 2 (June 2009): 67-74.

10 Ibid.

11 Ibid.

12 Ibid.

13 Katherine Shear, Angela Ghesquiere, and Kim Glickman, “Bereavement and Complicated Grief,”Current Psychiatry Reports15no. 11 (November 2013): 406.

14 Styron, DarknessVisible,50.

15 Kay Redfield Jamison, Nothing Was the Same: A Memoir (New York: Knopf Doubleday, 2009), 178.

16 Kristy Lamb, Ronald Pies, and Sidney Zisook,“The Bereavement Exclusion for the Diagnosis of Major Depression: To Be, or Not to Be,”Psychiatry(Edgmont)7, no. 7 (July 2010): 19–25.

17 Sidney Zisook, Ronald Pies, and Alana Iglewicz,“Grief, Depression, and the DSM-5,”Journal of Psychiatric Practice 19, no. 5 (September 2013): 386–396.

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Ronald W. Pies, MD, is professor of psychiatry, lecturer on bioethics & humanities at SUNY Upstate Medical University, Syracuse, New York; and clinical professor of psychiatry, Tufts University School of Medicine, in Boston, Massachusetts, United States.

Cynthia M. A. Geppert MD, PhD, MPH, is professor of psychiatry and director of ethics education, University of New Mexico School of Medicine; and chief, consultation psychiatry & ethics, New Mexico Veterans Affairs Health Care System, Albuquerque, New Mexico, United States.

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