The proposal before the DSM-5 work group of the American Psychiatric Association suggesting that most normal bereavement be included in the criteria for major depressive disorder is a decidedly bad idea. All people grieve when they lose a loved one. Grief has the same symptoms as depression, but not everyone who grieves is clinically depressed.
Under current guidelines, the diagnosis of major depressive disorder "is generally not given unless the symptoms are still present 2 months after the loss," according to the DSM-IV-TR (APA: Washington, 2000, p. 741). Conventional wisdom says normal grieving takes about 6 weeks. Research by George A. Bonanno, Ph.D., however, suggests that most grief is usually over within 6 months (J. Pers. Soc. Psychol. 2002;83[5]:1150-64).
If, after a period of time, the depressive symptoms do not go away, we can say that the grieving person is truly depressed. Notwithstanding this formulation, many doctors treat depressive symptoms as if they were dealing with a real depression with antidepressants. In far too many cases, such treatments are unwarranted.
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While grief and depression may have some of the same symptoms, not everyone who grieves is depressed.
The effort to include bereavement under a kind of depression is based on the same principle that the condition should be treated rather than the true diagnosis. I strongly oppose this approach. Few people understand the dynamics that lead a person who is grieving to become depressed, which I believe is the important issue being missed in this discussion. The dynamics are tied to the person’s feelings about the loss. One of the major underlying issues in depression is guilt over unconscious anger, for example. In fact, often, one of the key problems underlying depression is guilt.
However, guilt is only one of the psychological findings in depression. I would add three more: feelings of hopelessness, helplessness, and worthlessness. Without one or more of those ingredients, there is no depression. Obviously, giving the patient an antidepressant before talking with her allows us to miss these important clues.
Guilt Over Unconscious Anger
A good clinical example was a patient of mine – a 75-year-old woman who was very depressed after the suicide of her 50-plus-year-old son. She was convinced that she could have saved his life had a significant number of "if onlys" been in place, such as "if only she had brought him to Philadelphia; if only she had taken him to see a psychiatrist; if only she had gone out and stayed with him in San Francisco, and so on.
Her son was gay and lived with his partner, who was dying of AIDS. When the partner died, my patient’s son became despondent; after all, the love of his life had died. Eventually, he became suicidal. He had no interest in his mother’s advice or efforts to save his life.
For her part, she claimed no anger toward her son because of his sexual orientation, attachment to a dying man with AIDS, or "ceasing his life as a doctor." (However, she did criticize her son for many other reasons.) Despite her protestations to the contrary, my assessment is that the patient had significant guilt over unconscious anger toward her son. But like many patients, she had no interest in looking into herself or investigating how she really felt deep down inside. According to her, had she been able to carry out many of her life-saving methods, her son would have lived – and she would have been vindicated.
She had all of the usual symptoms of depression. Ultimately, she began to understand my formulation and slowly overcame her grief. She also felt helpless, hopeless, and worthless. But those issues were secondary to the true dynamic at work here: guilt over unconscious anger.
Psychoanalytic Underpinnings
In 1915, Freud published his monumental essay, Mourning and Melancholia, which outlined the dynamics that I’ve described above. It also led to the change in his theory of the instinctual drives being sex and self-preservation to sex and aggression. Most important, it distinguished between mourning for a dead loved one and depression.
Now, almost 100 years later, we are trying to change history and wipe out our psychoanalytic understanding of the distinction between mourning or bereavement and melancholia or depression. Not every resident in psychiatry intends to become a psychoanalyst as we did in the 1950s and ’60s. But to try to wipe the slate clean as if Freud never existed is a big mistake, especially in this context.
One of the realities of modern society is that we have nothing to do to resolve our anger at those we love who die. They become saints and the picture rarely, if ever, changes. We have an aversion to looking at a person’s life and recognizing that they were someone we disliked because of what they perpetrated against us. We use all kinds of mechanisms to deal with our negative feelings – rationalization, denial, and sublimation to wipe the slate clean. However, we are unwilling to discuss our ambivalence. Some of us portrayed Ronald Reagan and Richard Nixon as perfect after they died. There was even a suggestion that Reagan be added to the presidents on Mount Rushmore. We see the phenomenon all the time: Never speak ill of the dead. That tendency makes the guilt all the more awful in our minds, so we push it deep into the unconscious.