Grief/Depression III - Telling the Difference

Once, when I was seriously under and still headed down, a friend said to me, There have been times in my life when I was sad, so sad I couldn't imagine being any sadder. But it seems that what you and others with depression are describing is a whole different level that I know nothing about.

See, that's what would be helpful, instead of, I know just how you feel. I remember when [fill in the significant loss]... I knew that he knew times of deep sadness, because I knew some of those times, and because he is a person is thinks and feels deeply. And listens deeply. Everyone should have such a friend.

It was Social Hour. We were in a corner to protect me from all those people being social. I leaned against a wall, because I was very tired. I guess the wall gave me the idea. I said, Yes, there are times I have been so sad I couldn't imagine being sadder. It's like the sadness became a wall I could lean against, because I was so tired. But Depression IS different. Imagine if the wall gives way. Imagine there isn't a limit. You lean and the wall gives way.

At the time, I was just beginning the chemistry experiment that would eventually conclude:
  • Antidepressants do disastrous things to my brain and body.
  • Mood stabilizers are so marginally effective they are not worth the side effects.
  • Anti-psychotics increase risk factors for other health issues that are already serious risks for me, and I am not willing to go there. Unless I am psychotic. And can no longer hide it. Most of the time, I can manage my symptoms with anti-anxiety meds and occasional sleep aids.
  • Most of the time, I can manage my symptoms if I manage my exposure to stress and keep a regular routine.

Then My Mother Died

So there we have a trifecta of potential disaster:
  • Air travel/hotels/bursts of activity/disruption of routine;
  • All the issues/relationships/ reminders of old wounds/ expectations of new ones;
  • And, well, my mother died.

Is It Grief? Is It Relapse?

This is very scary. See above -- I can't take jigger my meds to make it go away. The meds I take don't make it go away. And most of the time that I can manage my symptoms isn't all of the time. So since January 14th, I have monitored my mood like it was a nuclear reactor about to blow.

DSM Criteria for Depression
  • Depressed mood - like, those waves of sadness punctuated by spontaneous bursts into sobs.
  • Marked diminished interest or pleasure in most activities - like, I was in Costa Rica. I didn't talk to my neighbors. I didn't buy vegetables from the vegetable man I really like. I didn't even see what surrounded me while I ate my breakfast on my patio.
  • Insomnia or hypersomnia - like, suddenly I was doing 9-10 hours every single night.
  • Fatigue or loss of energy - like, how could I wake up exhausted after ten hours of sleep?
  • Diminished ability to think or concentrate - like, I am the priest in the family, which meant the world to my Roman Catholic mother. And there was no way I was able to write anything to say at her funeral.
There are four other DSM criteria for a depressive episode (psychomotor agitation, changes in appetite and weight, feelings of worthlessness, suicidal ideation). But these were the ones that hit me. Five, including both of the top two, enough for a diagnosis by a doctor in a hurry.

Plus I have some trauma-related comorbidity issues. So add:
  • Recurrent and distressing recollections of past events, related dreams, more dreams, distress at exposure to reminders of the past traumas, and dreams
  • Avoidance of things that stimulate said distress, numbing
  • Anger, irritability, rage, hyper-vigilance...
And a mother load of anxiety. So to speak.

There I was, going through my mother's things, reading a draft of the will that will cause such pain and strain between siblings, trying to find important papers and a ring that had gone missing, sorting through pictures that reminded me of the sorrows in her life, reading the trauma in her own young eyes, sorrowing over the pain and disability of her last years...

I looked up from my breakfast table one morning and realized I hadn't even seen this flower that greets me every morning in Costa Rica. It lasted just a moment, my recognition. Then my eyes clouded over, and I couldn't see the flower again, or hear the birds and the howler monkeys.

After two weeks, it was onto another flight, to the funeral in Utah.

Monitoring my mood like it was a nuclear reactor about to blow, I knew --

I was depressed; I was not Depressed

How did I know the difference?  Because the wall held. When I was tired, when I was raging, when I was lost, I knew -- my mother just died!  I leaned up against the sadness of it. What I felt was natural, normal, and passing.

Then I Relapsed

A month after her death, well within the two month Bereavement Exclusion, the wall gave way. The depression became Depression, global, all-consuming, falling into the hole that has no bottom.

In true Depression fashion, the feeling of falling with no bottom led to the thought that I was doomed. There are no meds. There is no way out. Here I am again, years into therapy, years now with the right diagnosis and the right therapist, two therapists whom I trust, who double team me, chakra work on the left and cognitive behavioral therapy on the right.

It never goes away. It will never go away. This is the rest of my life, until I can no longer live it.

The Difference Between Grief and Depression

There is the difference between grief and Big-D Depression. It's just not in the DSM. The proximate cause of the symptoms is not sufficient to tell the difference. Neither is two weeks. Neither is two months.

The point is, it is perfectly possible to have both. People who have life-threatening depression can lose a loved one, just as easily as people who do not have a life-threatening depression. Bereavement is not a protective factor. In fact, it is a risk factor. People who have Big D- depression need treatment, regardless of whether their depressed mood makes sense in their context.

Ronald Pies and Sydney Zisook

These are the guys who caused all the fuss, convincing the first draft of the DSM V to eliminate the Bereavement Exclusion. They might have caused less fuss, if there were a description in the DSM of normal bereavement. I am not sure why it isn't there, except that the DSM does not describe normal.

Nevertheless, the Bereavement Exclusion has to go, because time has nothing to do with it.

For the Popular Audience

Start with The Two Worlds of Grief and Depression. Pies says it is not about where to draw the line, where grief crosses over into depression. They are two different things.

Telltale signs that my grief occupied different psychological territory than my previous and later depression:

  • I knew it was passing, that it would get better.
  • I did not feel isolated. I drew closer to my sister. The people who hang out at the Pato Loco told me they felt they got to know me better in those first two weeks than in the years I had been coming to visit.
  • My grief came and went in waves. There were sudden bursts into tears in public places, but they passed.
  • I was consolable. I could have fun. I could remember the good times, the funny stories, as well as the tragedies.

A month later it was different:

  • I was back to the illness that utterly defeats me. I get temporary breaks, but it has been wearing me down over my lifetime, and especially the last seven years, and may eventually kill me.
  • I did not contact my closest friends, and wanted to quit therapy.
  • The pall hung over the whole day, every day. When I did things for fun, I was really just going through the motions.

Treatment And Meds Are Not Necessarily The Same Thing

This is where the psychiatric community is stuck and where the story is distorted in the public understanding. Doctors have this auto-prescribing reflex: If it's in the DSM, a pill will fix it. But antidepressants have serious side effects. So you don't want to make a mistake and give them to people who don't need them, like people who are going through a normal grieving process that only looks like Major Depression to the doctor who has fifteen minutes before the next patient.

Wrong. Harmful. Potentially dangerous.

The real problem is the prescribing practice, not the risk of false-positives in diagnosis.

I needed treatment. I am getting it. Though I wanted to quit therapy, though it is a struggle to make myself go, I am going. I am walking, 1-4 miles/day. I am going to support groups, and making myself tell my story, and getting support. I am not trying new chemistry experiments.

The Brain Science

In The Anatomy of Sorrow: A Spiritual, Phenomenological and Neurological Perpective, Pies expands on his description of the overlapping but distinct worlds of grief and depression in relational, temporal, dialectical and intentional realms.

It turns out, the neurocircuitry of grief and depression are different. Some day brain doctors won't read tea leaves. They will actually do diagnostic testing, like heart doctors and lung doctors.

But gee, just as I get to the fMRI's, I run out of room and out of week.

Brain Science of Bereavement To Be Continued...

Note added 01/02/13 -- Other links in this series are listed below:

Grief? Depression? Both? January 28, 2012 -- The contexts of DSM revision debate over the Bereavement Exclusion: health care costs, the DSM and the inadequacy of symptom silos, the mind/brain debate, poor health care for the bereaved.
Grief/Depression II -- Rise in Rates of Mental Illness February 16, 2012 -- More context: stress and big pharma. This post begins my correspondence with Dr. Ronald Pies.
Grief/Depression IV -- Not the Same/Maybe Both March 1, 2012 -- Biomarkers for depression and grief.

Painting of Wailing Wall by Gustav Bauernfeind (1848-1905), in public domain
flair from
photo of Bird of Paradise by Helen Keefe, used by permission


  1. Thank you Willa. Your description of the wall is particularly helpful.
    Love and blessings,

  2. Dear Willa--

    Many thanks for this vivid description of two different "inner worlds": grief and major depression. I appreciate the call-out to the work Dr. Zisook and I have done (though Dr. Zisook has really done the primary research--I have mostly explored the subjective experiences of grief and depression). I have two new pieces that may be of interest to you and your readers:
    The first is now online at Psychiatric Times, and involves a potential screening tool, the PBPI, that helps distinguish ordinary grief from clinical (major) depression. [Alas, a free registration step is required to view pieces on PT]. The second is a blog that should appear in a few days on the Psychcentral website, which goes into some detail on why the bereavement exclusion in DSM-IV is not helpful and can confuse the diagnosis in some recently-bereaved individuals who meet all the criteria for a major depression. I'll plan to send you files of these soon. Thanks again for your advocacy and brave self-disclosure!

    Best regards,
    Ron Pies MD


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