We often hear the term "depression" bandied around in everyday conversation, but many do not know that this term has numerous meanings--meanings from the superficial such as, "I'm depressed my team lost the basketball game," to a general feeling of malaise, to normal grief, to the clinical use of the term for a major illness. Bereavement or grief is a natural state springing from loss, whereas depression is a mental illness.
According to the DSM-5, the bible of mental health and substance use diagnoses, there are numerous types of depression, but for this review, we are only examining persistent depressive disorder (Dysthymia) and major depressive disorder (MDD). These are the most significant of depressive illnesses. The two disorders can also be experienced at the same time.
Let’s begin by looking at these two types of depression and then explore the meaning of bereavement.
The 2 Major Types of Depression
This is a depression of lesser severity than MDD but is also a problematic illness due to its long-lasting nature.
Diagnostic criteria include:
- Depressive mood throughout the day
- Lasting for at least two years
- Two or more of these symptoms. including low self-worth, poor sleep or too much sleep, feeling hopeless/helpless, overeating or undereating and/or poor appetite, low energy, and poor concentration and problems making decisions
- Exclusions from the diagnosis, such as not being the symptoms of another diagnosis like bipolar disorder, and not due to the effects of a substance or a medical condition, must be explored
- Must be causing problems related to social, occupational, and other functioning areas of life
2. Major Depressive Disorder
This disorder is what is often described as the classic diagnosis of depression. It must not be confused with grief and sadness, which are normal processes. To be diagnosed, you must have a depressed mood and/or loss of pleasure along with five or more of any of the following symptoms for a minimum of two weeks.
Diagnostic criteria include:
- Depressed feelings daily and most of the day
- Anhedonia/detachment (loss of pleasure/interests)
- Increase or decrease in weight/change in appetite
- Chronic insomnia or sleeping too much
- Agitation such as restlessness or feeling slowed down
- Fatigue/lack of energy
- Inappropriate guilt or feeling helpless/hopeless or worthless
- Poor concentration/lack of ability to focus and indecisiveness
- Ongoing thoughts of death or dying, suicidal thoughts, a suicide plan
- Symptoms cause problems related to occupation, activities of daily living, social/relationships, and other problems in the level of functioning
- Symptoms not related to other disorders including substance use or a medical disorder
When It’s Grief, Not Depression
Unfortunately, the DSM-5 does a poor job of looking at normal grief and bereavement. Because of this, and because of Western society's difficulty with coping with grief in a healthy, healing manner, many individuals may be misdiagnosed with dysthymia or major depressive disorder.
We, including well-intentioned medical professionals, tend to downplay our grief as normal and healthy. We may decide that it is really depression and something that can hopefully be "cured" with medications. But normal grief cannot be healed with medicine, for it is a natural response to loss.
DSM-5 is looking at bereavement only as related to death and obviously, there are many other types of loss that need to be grieved, such as divorce, trauma relative to war or rape, physical abuse, family dysfunction, chronic health problems, death of a pet, and many other losses.
Normal grief can be experienced in many ways—crying, wailing, stoicism, peaks of feeling good surrounded by the depths of loss, feelings of love and feelings of devastation, a need to be alone or a need to be surrounded by loved ones. Though traditional thought may only conceive five stages of grief, there are myriads of ways that people grieve naturally. Grief comes of its own accord with a calm before the tsunami—the big wave and then, perhaps, a calmness again. Unfortunately, the DSM-5 is only looking into Persistent complex bereavement disorder, which surrounds death and only death. Grieving is unhealthy, and it is a condition that needs further study. It is not a diagnosis at this point.
In summary, healthy bereavement, dysthymia, and major depressive disorders are ones that many may experience in life. Untreated grief may lead to depression. We need to understand illness versus healthy grief in order to be able to treat it successfully. These mental health issues can also be impacted by substance use disorders, leading to co-occurring disorders of mood and substance abuse.