Bereavement and depression + determining distress or impairment

[sozme]

Had patient recently (outpatient internal medicine/primary care) who is in her late 60s, recently lost one of her adult children unexpectedly. At initial visit, it was noted that patient lost like 45-50 pounds in a 4 month period (from the month her son died to the initial office visit) - taking her from moderately overweight to "normal" weight per BMI. Other than that, she had obvious depressive symptoms. Won't get into nitty gritty of the medical issue she was there for, but because of her weight loss, she was scheduled for F/U a month later.

At the second visit a month later, it is obvious that she still has major depressive symptoms, but has stopped losing weight (even gained 2 lbs). Patient is gainfully employed, but admits to have absolutely no joy in life, sleeping 12 hours per night some nights and 0 hours other nights, excessively fatigued all the time, no interest in old hobbies, etc.. Despite this, she still manages to perform her job functions without any problem (though obviously derives no joy from her work).

She wont take antidepressants or consider therapy because she has had "bad experience" with medication in general in the past, and just kind of thinks its better to press through it.

To me she is the picture of major depression.

But she does really qualify for a diagnosis of depression?

Her symptoms, though severe, don't seem to interfere with her social or occupational functioning. As far as "social" is concerned, she was a loner before she was depressed and is still a loner now, with the only exception that she sees her grandchildren somewhat regularly (but at the same or more frequency than she used to before her adult son passed away). So I'm not sure what I'm supposed to judge as "social" functioning, since it seems more or less the same.

Additionally, what is the proper "problem list" diagnosis for depression with bereavement? I see things in the EMR like "bereavement reaction" but that doesn't seem like a psychiatric diagnosis to me...

I guess this is also a question about what constitutes "clinically significant distress or impairment in social, occupational, or other important areas of functioning."

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[splik]

personally someone in their late 60s who loses 50lbs in 3-4 month periods (how much did she weigh before?) I would want to worked up for malignancy in the first instance. I really think that the removal of the bereavement exclusion for MDD was a mistake, the issue is whether she has a normal or morbid grief reaction.

Edit: It sounds like you do not have much experience/understanding of grief and its relation to psychiatry.

Have a look at the dual process model of coping with grief which is more current than Kubler-Ross's model or Colin Murray Parkes' model (the latter is quite similar to the former though Murray Parkes was heavily influenced by attachment theory which was developing at the time). You may also be interested in postmodern and narrative approaches to grief which are in vogue today. Also Erich Lindemann's classic paper on the symptomatology of acute grief from 1944 (still as good today as it was then). My favorite text on grief therapy is Worden's classic grief counseling and grief therapy
To get some background on the removal of the breravement exclusion you may be interested in Ken Kendler's study finding little different between grief related depression, and depression due to other life events. Sid Zisook's paper (he was one of the chief proponents of grief reactions as psychiatric disorder) distinguished normal, prolonged, and depression-related grief.

Conversely, in The Loss of Sadness Horwitz and Wakefield argued the DSM-IV bereavement exclusion should be expanded to all loss events as they believed that we unnecessarily medicalize normal reactions to sadness, and inappropriately conflate "biologically-based" depressions with normal variants of sadness that are adaptive. I have some sympathy for this.

Finally, all psychiatrists should read Freud's class Mourning and Melancholia where he first compared depression to the state of mourning, noting melancholics wish to obliterate all memory of the lost object, while a person in mourning fears they will be unable to remember the loss object.

 

[sozme]

personally someone in their late 60s who loses 50lbs in 3-4 month periods (how much did she weigh before?) I would want to worked up for malignancy in the first instance. I really think that the removal of the bereavement exclusion for MDD was a mistake, the issue is whether she has a normal or morbid grief reaction.

She was overweight before, went from about 190 to 140 or so (BMI normal). But in the past month, she has stopped losing weight (even gained 2 lbs). I edited the OP to clarify this.

I'm curious to know why you think removal of the bereavement exclusion was a mistake? From my understanding the reasoning had to due with risk factors for suicide being the same regardless of whether or not bereavement plays a role.

 

[Merovinge]

From my understanding the reasoning had to due with risk factors for suicide being the same regardless of whether or not bereavement plays a role.

That's correct. I would strongly push for therapy and explain the rationale in a way most likely to entice her ( this requires figuring out her wants/personality a bit). Splik can opine about various models of grief all day but her suicide risk is clearly elevated and QoL is clearly negatively impacted which is silly when we have treatment available.

 

[singasongofjoy]

Maybe you've already looked at this but FWIW here's what the DSM-5 has to say about distinguishing grief from a major depressive episode: ". . . it is useful to consider that in grief the predominant affect is feelings of emptiness and loss, while in MDE it is persistent depressed mood and the inability to anticipate happiness or pleasure. The dysphoria in grief is likely to decrease in intensity over days to weeks and occurs in waves, the so-called pangs of grief. These waves tend to be associated with thoughts or reminders oft he deceased. The depressed mood of MDE is more persistent and not tied to specific thoughts or preoccupations. The pain of grief may be accompanied by positive emotions and humor that are uncharacteristic of the pervasive unhappiness and misery characteristic of MDE. The thought content associated with grief generally features a preoccupation with thoughts and memories of the deceased, rather than the self-critical or pessimistic ruminations seen in MDE. In grief, self-esteem is generally preserved, whereas in MDE feelings of worthlessness and self-loathing are common. If self-derogatory ideation is present in grief, it typically involves perceived failings vis-a-vis the deceased (e.g., not visiting frequently enough, not telling the deceased how much he or she was loved). If a bereaved individual thinks about death and dying, such thoughts are generally focused on the deceased and possibly about t"joining" the deceased, whereas in MDE such thoughts are focused on ending one's own life because of feeling worthless, undeserving of life, or unable to cope with the pain of depression."

Sounds like therapy might be helpful if she was open to it; however, since she is not (and I assume you've assessed risk of self-harm as low and assessed for some coping strategies etc), I would not push so hard as to risk damaging rapport unless her symptoms take a different turn and worsen. She might be more open to the idea of therapy in the future if she's still having a hard time a few months from now but if she's not ready to engage now, goes to therapy, and doesn't get much out of it because the time isn't right and she's not following through with things between sessions, she might be even more resistant to going in the future if/when she needed it. Maybe for now she would at least be open to doing some tracking of her mood a few times throughout the day? That way at followup you'd have some data to look at to see if her mood was improving (or not), over time, and if it wasn't and she was the data, she might be more open at that point . I think it's hard for patients to look back over the whole month (or more) and make an objective assessment about whether they're experiencing incremental change either for the better or the worse, especially if they are depressed and that's affecting their recall. Their report can be quite colored by how they feel in the moment. sometimes looking at the daily reports like that I'll see something quite different than what the client is telling me when I ask and they respond off-the-cuff.

 

[Ceke2002]

Had patient recently (outpatient internal medicine/primary care) who is in her late 60s, recently lost one of her adult children unexpectedly. At initial visit, it was noted that patient lost like 45-50 pounds in a 4 month period (from the month her son died to the initial office visit) - taking her from moderately overweight to "normal" weight per BMI. Other than that, she had obvious depressive symptoms. Won't get into nitty gritty of the medical issue she was there for, but because of her weight loss, she was scheduled for F/U a month later.

At the second visit a month later, it is obvious that she still has major depressive symptoms, but has stopped losing weight (even gained 2 lbs). Patient is gainfully employed, but admits to have absolutely no joy in life, sleeping 12 hours per night some nights and 0 hours other nights, excessively fatigued all the time, no interest in old hobbies, etc.. Despite this, she still manages to perform her job functions without any problem (though obviously derives no joy from her work).

She wont take antidepressants or consider therapy because she has had "bad experience" with medication in general in the past, and just kind of thinks its better to press through it.

To me she is the picture of major depression.

But she does really qualify for a diagnosis of depression?

Her symptoms, though severe, don't seem to interfere with her social or occupational functioning. As far as "social" is concerned, she was a loner before she was depressed and is still a loner now, with the only exception that she sees her grandchildren somewhat regularly (but at the same or more frequency than she used to before her adult son passed away). So I'm not sure what I'm supposed to judge as "social" functioning, since it seems more or less the same.

Additionally, what is the proper "problem list" diagnosis for depression with bereavement? I see things in the EMR like "bereavement reaction" but that doesn't seem like a psychiatric diagnosis to me...

I guess this is also a question about what constitutes "clinically significant distress or impairment in social, occupational, or other important areas of functioning."

Do you know if there's any sort of personality disorder at play? The reason I ask is this case sounds very similar to how my Mum responds to grief, and my Mum just happens to display symptoms of Borderline and Histrionic PD which I think may colour how she works through the grief process (to the point that it can look very, very similar to an episode of MDD). I was just wondering if the same could possibly be said of this patient as well?