Is Bereavement Part of Depression? And What the Hell is Depression, Anyway?

Willa Goodfellow’s latest Prozac Monologues piece raises the very important discussion about how bereavement fits (or not) into depression. Ronald Pies, one of the two principal figures behind the proposed DSM-5 “bereavement exclusion” to the depression diagnosis, has left a comment.

The discussion is framed in such a way that the nominal topic - bereavement - unlocks the key to the real issue, namely can any two people actually agree on what depression is all about? What about depression-like behavior?

Some background: The DSM-IV expressly rules out the depression diagnosis if the symptoms are attributable to bereavement for a period of two months or less. The DSM-5, due out in 2013, would drop this exclusion. This has created the mistaken notion that the DSM-5 is proposing to turn bereavement into a psychiatric illness. Allen Frances, who oversaw the DSM-IV, recently told the NY Times that “the revisions will medicalize normality.”

Let’s turn to what the DSM-5 is actually proposing. In the updated depression diagnosis, the symptom checklist would stay the same. In the fine print below, this gets the axe:

“The symptoms are not better accounted for by Bereavement ...”

Willa’s post sees this as the last piece in restoring the complete depression diagnosis. She points out that the DSMs I and II attempted to separate out depressions they saw as situational (exogenous) from those they saw as biological (endogenous). The DSM-III abolished this distinction, essentially viewing depression as a depression, but left in bereavement as an exception. The DSM-IV continued with this.

Willa asks us to view depression as something that happens when life throws too much at us, a point of view backed by some very impressive brain science. Some of us may be genetically resilient, but others (namely, us) prove highly vulnerable, owing to a hyperactive stress response. Says Willa:

What difference does it make whether the one damn thing too many is loss of a job or loss of a loved one?  It's still one damn thing too many.  And doctors need to take time to figure out what is going on with the person sitting in the office on her last nerve, not say, “There, there. You'll feel better in a couple months.”

As Dr Pies’ says in his comment:

[If] it looks like a duck, walks like a duck, and quacks like a duck, it's likely to be a duck, until proved otherwise. That is: if a patient shows up in the doctor's office meeting the full symptom and duration criteria for Major Depressive Disorder(MDD); but happens to have lost a loved one within the past two months, we should not withhold the diagnosis of MDD, simply because it occurs in the context of bereavement.

Are we clear on this? Good. Now let’s muddy it up. In an article on my website, Placing Depression in Context, I too observe the old clinical vs situational distinction, with reference to the DSMs I and II, and like Willa I view the distinction as naive and unscientific. But, nevertheless, I also see merit in bringing back some of the old reasoning. As I put it:

The endogenous-exogenous distinction does encourage us to examine where our depression might be coming from. If your marriage is falling apart, for instance, or your situation at work is going badly, it is obviously worth exploring this association. Sort of like investigating whether a person with a pulmonary disorder is working in an asbestos mine. For some crazy reason, the "modern" DSM-III of 1980 and its successors didn't think this was important.

I also looked at normal vs abnormal. In other words, are some of our depressions a normal reaction to an abnormal situation? Aren’t we supposed to feel depressed when we have lost a loved one? Moreover, if life is getting to be too much for us, our depressions may be telling us that we may need to make an immediate course correction. From my article:

This is straight out of evolutionary psychology. Depression has been called the end of denial. The rose-colored glasses come off. Reality takes over. Maybe instead of banging your head against the same wall - again and again and again - you need to cut loose destructive friends, bail out of a bad relationship, rethink that toxic work environment.

Listen to your depression. It may be an unwelcome guest in your brain, but it is definitely telling you something.

But my article also describes a situational depression I found myself in back in 2004, one that very easily could have led to a clinical depression. I simply did not have the luxury of leaving things to chance, not with my vulnerable brain. I immediately changed my routines and found a new project to work on.

In other words, I was feeling depressed. I needed to act right now.

This is precisely Willa’s point. Prior to reading her piece, I was on the side of not changing the bereavement exclusion. Now I’m teetering the other way. But this is because Willa’s piece challenged me to rethink depression, not bereavement. Depression is never what we think we think it is. Something to think about ....

Willa Goodfellow's Prozac Monologues: Still Going Strong

I’ve been telling people for years that my beat covers everything from God to neurons. A month or two ago, I incorporated “From God to Neurons” into the subtitle of Knowledge is Necessity. In mid-2009, I had the pleasure of discovering online the other person on the planet blogging from God to neurons, Willa Goodfellow (pictured here).

Willa was only a few months into her vastly wise and funny and totally unique Prozac Monologues. My hypomanic delight over my find was muted by my ever-faithful depressive realism. As I put it in a review at the time:

"Promising bloggers have an unfortunate tendency to burn out, so I urge all of you to drop a comment on her blog site offering encouragement. To Willa: It's very easy for bloggers to get discouraged, particularly when dealing with depression. But clearly we need you. Stick with it."

Willa stuck with it, and we established a great online friendship. Last summer, I had the pleasure of meeting her face-to-face at the NAMI national convention in Chicago. Think of below as a Willa sampler from the past several months. Enjoy, then check her out for real ...

Yes, we ARE getting sicker.  We live in times that make us sick.  We struggle to pay bills while our bosses speed up the assembly line.  Those of us who don't get laid off can't quit, because we can't afford health insurance.  Our support systems, extended family, neighborhoods, religious communities, social organizations - the buffers of stress - have been ripped away, replaced by reality TV and Facebook hysteria.

***

Keep skunks and bankers at a distance.

Live a good and honorable life.  Then when you get older and think back, you'll enjoy it a second time.

Timing has a lot to do with the outcome of a rain dance.

If you get to thinking you're a person of some influence, try ordering somebody else's dog around.

***

... This is why, if your antidepressant works for you, you are just plain lucky.  It happens to treat the problem in your particular brain.  Most of the time, it treats somebody else's problem.

***

While God was blessing Tim Tebow's hard work on Sunday afternoon, 720 children around the world died of hunger.  270 people committed suicide.  Two of them, by the way, were veterans of the United States Armed Forces.

That was before overtime.  Good thing overtime was short, huh?

So on Monday morning, nearly 1000 mothers were asking, If God could help Tim complete that pass, couldn't he have paid some attention to my child?  Billions still listen for their answer.

***

For the Israelites, the Babylonian Exile resulted in an explosion of creativity, poetry, philosophy, history, new forms of worship, the legal code, and the development of a religion that was larger than their prior notions of land=success=God's favor.  They came up with a religion that could handle exile, handle loss.  It could travel and face the future.

Their brains found new patterns. ...

***

I'm into changing my brain.  In that mass of electrical wiring, some potentially healthy pathways are blocked by the detritus of dead dendrites.  Other destructive pathways are carved into canyons of well-worn automatic responses.

Changing my brain will take time.  It is taking decades.  It will take at least another blogpost.

***

From the Damned-If-You-Do-And-Damned-If-You-Don't Department, the medications for schizophrenia and bipolar mostly reduce the positive symptoms (delusions in the case of schizophrenia, high energy in bipolar - the symptoms that scare your families and your care providers who write the prescriptions).  They tend to increase the negative symptoms (thereby relieving the anxieties of your families and your care providers who write the prescriptions), providing that synergistic effect that nails you to the sofa.

***

Evidently inspired by Fox News, Merry Christmas is no longer an expression of joy and good cheer, but a battle cry against the First Amendment and the great American experiment of freedom and tolerance of difference.

***

Inevitably, certain symptoms get more attention than others.  Psychiatrists are not concerned when patients sleep too much, do an astounding amount of work in three days or die twenty-five years before our natural lifespan due to complications of obesity, as long as we don't have hallucinations or delusions or try to end our misery by self-harm.

It's all about the descriptors, and how nervous they make people. ...

It's like, the DSM tells you what color the car is and how many cup holders it has.  Big Pharma has made a lot of money tinkering with the placement of the cup holders.  Meanwhile, what patients want to know and what scientists actually are working on nowadays is, what's under the hood?

***

Mahatma Gandhi was not the first freedom fighter.  But he is the great theoretician.  He gave us the map.

First they ignore you.
Then they laugh at you.
Then they fight you.
Then you win.

Four simple steps.  The good news -- we have already taken the first.  Got that one down pat.

Go to Prozac Monologues ...

The Hypomania Dilemma

I love reading Willa Goodfellow's blog, Prozac Monologues. Willa (pictured here) is smart, insightful, and like all good writers she poses questions rather than serving up easy answers. Case in point:

Willa's wife Helen was invited to a function at the home of Sally Mason, president of the University of Iowa. Willa got to tag along. As she explains it:

Helen likes to show me off, because I am good at parties, can talk with anybody, good social skills. And I am cute.

So far, so good.

Anticipating wine at the function, she decided to skip her afternoon Valium. Besides, she wanted to be mentally sharp. Later into the function, the host engaged Helen and Willa in a conversation. They were standing in front of a bookcase populated with books by Iowa Writers Workshop authors. The workshop is the pride and joy of the university.

In Willa's words, "That is when the evil twin appeared." Pointing to a Pulitzer book, "Gilead" by Marilynne Robinson, the evil twin let loose: "Boring. Boring, boring, boring."

Gracious host that she was, Dr Mason acknowledged it was a difficult book to read. Willa says she could have redeemed herself by offering that it was difficult for her, as well. After all, the book was about depressed small town Iowa clergy, and - guess what? - Willa had been one herself. All manner of fascinating conversation could have flowed.

But, no. Willa pointed to another book. As she reports: "This time I said, 'I hate this book ...'" Dr Mason moved on to other guests.

Willa observes that her psychiatrist would have a ready solution to her unwanted hypomania, namely to go on the meds she had been refusing. But there is a catch, as Willa relates:

Those meds would give me a flat affect, facial tics and forty pounds. Helen would have no reason to let me out of the house at all. I would no longer even be cute.

Willa cites a 2003 study by Pope and Scott that pointed to a clear discordance between psychiatrists and patients. The psychiatrists in the study thought that bipolars went off their meds because we "miss our highs." The patients who quit cited other reasons. In 2006, I heard Dr Scott talk about her study at the International Society of Bipolar Disorder conference in Edinburgh. When I included it as a PowerPoint slide in a grand rounds I gave two years later to clinicians at a hospital in Princeton, NJ I was greeted with stony cold frozen Kelvin grade silence.

It didn't help when the next thing out of my mouth was: "Get over it. When your patients complain to you about feeling like fat stupid zombie eunuchs on the meds you prescribe - and on the meds you overprescribe - they are not doing this to ruin your day."

In an ideal world, we could all be our smart, funny, insightful, and engaging selves without having to worry about causing a social embarrassment. Operating with a clear head is our most valuable asset, but there are risks, illness or no illness. I could opt for faux pas-free life, but at what cost? An existence devoid of laughter?

Psychiatrists tell us we need to stay on our meds, and for many of us that is very good advice. But that is the easy answer. Willa poses questions ...

PTSD - Since When Is An Event Supposed to Justify a Condition?

My good friend Willa Goodfellow (Prozac Monologues) has written an extremely thought-provoking blog piece on PTSD. She summarizes a 2004 article by neuropsychiatrist Nancy Andreasen of the University of Iowa. How we view the condition can be largely attributed to Dr Andreasen.

The phenomenon has been around since the beginning of time, but our understanding remains limited. During World War I, soldiers who experienced "shell shock" were shot as cowards. In World War II, soldiers who suffered "battle fatigue" were given "therapy" to return them to combat in one week. (The therapy, such as exposure to recorded artillery fire sounds, typically exacerbated their distress.) General Patton infamously slapped a bed-ridden soldier.

The postwar DSM-I of 1952 recognized "gross stress disorder," but this was removed from the DSM-II of 1968. The post-Vietnam War era set the scene for its comeback in the DSM-III of 1980. Dr Andreasen was charged with the task of looking into "post-Vietnam syndrome." As Willa describes it:

Given her experience with burn victims, Andreasen pressed for a more inclusive description of the illness. Post Traumatic Stress Disorder entered the new edition, described as a stress reaction to a catastrophic stressor that is outside the range of usual human experience.

Unlike all other mental illnesses, the first criterion for a PTSD diagnosis is an event rather than  a symptom. Another way of putting this is that the DSM mandates a valid reason for an individual's response. The DSM-IV of 1994 and this year's draft DSM-5 (due out in 2013) simply play around with the scope of the valid reason. The 1994 version widened the criterion to include events not necessarily outside the range of human experience (such as surviving an auto accident) while the DSM-5 would narrow it again.

Compare this to depression. Psychiatry does not require a valid reason for us to rate a diagnosis. To the contrary, a valid reason - such as bereavement - would rule out a diagnosis (unless the depression were to persist). In this context, depression would be a normal response to an abnormal situation. We are supposed to feel depressed when we lose someone close to us.

We often get clinically depressed for seemingly no reason at all. Since there is no logic to the depression, the thinking goes, we must be thinking and behaving irrationally. And if this significantly interferes with our daily life, we are presumed to have a mental illness. We elicit sympathy or opprobrium, as the case may be.

The same applies across the anxiety spectrum (with the notable exception of PTSD). We don't need a valid reason - such as an intruder entering through the window - to justify a panic attack. Being frightened of your own shadow will do just fine.

So, I'm wondering. What happens to the poor individual who suffers severe trauma for a stupid reason? Not from combat. Not from being exposed to an act of God or an unspeakable outrage. Something stupid, really stupid. Such as perhaps a close encounter with a circus clown. The trauma may be irrational, but then again so is all the rest of mental illness.

Is that person's distress any less?

Suppose two people rupture their ACL. Does the person who ruptured his ACL while playing basketball get treated while the other individual who ruptured hers playing with her dog get sent home? Isn't it the condition - rather than the precipitating event - we're supposed to be treating?

There are no easy answers here. But the questions, the questions ...

The Draft DSM-5 - Another Blogger Speaks Out

I'll be quick: Blogger comrade-in-arms Willa Goodfellow (pictured here) of Prozac Monologues has written a terrific critique of the Draft DSM-5. Sample:

Particularly disturbing is the failure to include new knowledge about Bipolar II.  The proposed revisions do not even keep pace with practice among psychiatrists who do listen to their patients' experience.  The evidence for a link between antidepressants and suicide is most compelling for those who are diagnosed with Bipolar II or those who could be diagnosed with Bipolar II, if the criteria shifted to include them.  The continued narrow definition leads to inappropriate treatment with antidepressants (translation: more sales of antidepressants), and deterioration, including a tripled risk of suicide. 

Say no more. Check it out ...

Surviving the Holidays

Shortly before Thanksgiving, on BipolarConnect, I offered this holiday advice:

• Keep your expectations low. We tend to do the very opposite, then find ourselves dealing with the disappointment. You will be a lot better off if you don't think of the holidays as a time to strengthen your bond to your loved one, impress your parents, reconcile with a difficult brother or sister, or be a hero to your nieces and nephews.
• Take time out for yourself. The holidays put us in situations where we are easily overstimulated and overwhelmed. If you sense a force nine family fight about to break out at the table, don't be afraid to summarily remove yourself from the scene. The same holds true even if there is no family tension, even if everyone is enjoying themselves. You don't need a good excuse to make an exit - any bad one will do.
• Plan ahead. The less surprises the better. The less last-minute rushing around the better.
• Figure out your needs. Some of us need to be around people. Some of us are better off taking a Sabbatical from humanity. Don't let family obligations and other duties affect your decision. We are all dealing with a severe chronic illness, with huge consequences when things go wrong. Interpersonal stresses can set us up for a crash and burn at one end, isolation can make us sitting ducks at the other. The only wrong decision is the one you make against your own best judgment.

Finally: Don't be afraid to have a happy holidays. They have been known to happen.

Two of my favorite bloggers, Therese Borchard of Beyond Blue and Willa Goodfellow of Prozac Monologues cover the territory with a lot more depth and insight. On a normal day, their blogs are to me what coffee is to Starbucks. For the holidays, they are a must-read:

From Willa:

• Don't You Love the Holidays?
• At the Movies
  

From Therese:

• 21 Holiday Stress-Busters
• 10 Tips for Steps for Stepfamilies
• Holiday Stress Tips
• Depression Before the Holidays