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Clinical features distinguishing grief from depressive episodes: A qualitative analysis
Journal of Affective Disorders 176 (2015) 43–47
Contents lists available at ScienceDirect
Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Research report
Clinical features distinguishing grief from depressive episodes: A qualitative analysis Gordon Parker a,b,n, Stacey McCraw a,b, Amelia Paterson a,b a b
School of Psychiatry, University of New South Wales, Sydney, Australia Black Dog Institute, Sydney, Australia
art ic l e i nf o
a b s t r a c t
Article history: Received 4 December 2014 Received in revised form 30 January 2015 Accepted 31 January 2015 Available online 7 February 2015
Background: The independence or interdependence of grief and major depression has been keenly argued in relation to recent DSM definitions and encouraged the current study. Methods: We report a phenomenological study seeking to identify the experiential and phenomenological differences between depression and grief as judged qualitatively by those who had experienced clinical (n ¼125) or non-clinical depressive states (n ¼ 28). Results: Analyses involving the whole sample indicated that, in contrast to grief, depression involved feelings of hopelessness and helplessness, being endless and was associated with a lack of control, having an internal self-focus impacting on self-esteem, being more severe and stressful, being marked by physical symptoms and often lacking a justifiable cause. Grief was distinguished from depression by the individual viewing their experience as natural and to be expected, a consequence of a loss, and with an external focus (i.e. the loss of the other). Some identified differences may have reflected the impact of depressive “type” (e.g. melancholia) rather than depression per se, and argue for a two-tiered model differentiating normative depressive and grief states at their base level and then “clinical” depressive and ‘pathological’ grief states by their associated clinical features. Limitations: Comparative analyses between the clinical and non-clinical groups were limited by the latter sub-set being few in number. The provision of definitions may have shaped subjects' nominated differentiating features. Conclusion: The study identified a distinct number of phenomenological and clinical differences between grief and depression and few shared features, but more importantly, argued for the development of a two-tiered model defining both base states and clinical expressions. & 2015 Elsevier B.V. All rights reserved.
Keywords: Grief Depression Assessment Diagnosis Qualitative
1. Introduction In this report we pursue the phenomenological distinction of depression and grief. As summarised by Shear (2012), grief's hallmarks are yearning and sadness which emerge from the loss of the “other” and with self-esteem generally preserved, and in contrast to depression where the person views their own self as empty or impoverished —as differentiated by Freud (1917). A similar distinction is provided in a DSM-5 sub-script (p 161), where it is noted that the predominant affect in grief involves “feelings of emptiness and loss” while, in depression, it is a “persistent depressed mood and the inability to anticipate happiness or pleasure”. Further, the sub-script states that the preoccupying thought content in grief involves “memories of the
n Correspondence to: Black Dog Institute, Prince of Wales Hospital, Randwick 2031, Sydney, Australia. E-mail address: [email protected] (G. Parker).
http://dx.doi.org/10.1016/j.jad.2015.01.063 0165-0327/& 2015 Elsevier B.V. All rights reserved.
deceased” rather than the “self-critical or pessimistic ruminations” integral to depression, and that self-esteem is generally preserved in grief whereas in major depression “feelings of worthlessness and selfloathing are common”. Differentiation is nevertheless often difficult as individuals and patients may not define their emotional states quite so pristinely. Further, the two states may co-occur, making their formal differentiation even more difficult. Definitional and differentiation issues between grief and clinical depression have been wrestled with since DSM-III introduced the “major depressive disorder” (MDD) category, and with researchers and clinicians subsequently raising concerns that an episode of grief could manifest symptoms making an individual eligible for a MDD diagnosis (e.g., Clayton, 1990; Zisook and Shuchter, 1991). During the initial stages of an acute grief reaction, it might be expected that the presence of distinctive “depressive” symptoms would not be interpreted as necessarily indicative of a depressive disorder if the bereavement context is taken into consideration. The DSM-IV formalised this
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nuance by including bereavement as an exclusion criterion for a major depressive episode—unless depressive symptoms persist for more than two months after the bereavement, are gravid and uncharacteristic of normal grieving (e.g., suicidal ideation, psychotic symptoms, or psychomotor retardation) or are associated with marked functional impairment. This exclusion criterion sought to avoid pathologising normal grief responses in the estimated onethird to one-quarter of individuals who would otherwise meet MDD criteria if assessed within two months of bereavement (Zisook and Shuchter, 1991; Clayton et al., 1972). The DSM-5 notes that responses to a significant loss such as bereavement “may resemble a depressive episode”, with overlapping symptoms usually including insomnia, appetite and weight loss, rumination about the loss, and intense sadness, therefore somewhat blurring distinction. In contrast to DSM-IV, DSM-5 does not state that responses to significant loss are exclusion criteria for major depressive episodes, but instead instructs practitioners to “exercise clinical judgement” in determining whether a grief response is accompanied by a MDD depressive episode, and by evaluating what would be expected to be the “normal response to a significant loss” given the individual's history and consideration of cultural norms. DSM-5 also allows that “responses to a significant loss” are not limited to grief caused by a break in a social bond (bereavement), but also lists financial ruin, losses from a natural disaster, serious medical illness and disability as exemplars, and risks some conjoining of the two states. The controversy generated by the DSM-5 classification (Maj, 2012; Parker, 2013; Wakefield, 2013; Wakefield and First, 2012) contributed to undertaking the present study, which seeks to identify phenomenological points of distinction. Previous study findings have variably reported substantive and minimal differences between the two states. For example, one US longitudinal epidemiological study reported that episodes of grief were prototypically different from standard major depressive episodes in being less likely to involve impairment in role functioning, fatigue, hypersomnia, feelings of worthlessness or suicide ideation (Mojtabai, 2011). In addition, bereaved individuals did not demonstrate an increased risk to future depressive episodes and were less likely to need medication or psychological therapy for depression and so differed from those with nonbereavement-related major depressive episodes. In relation to differing treatment responses, Reynolds et al. (1999) reported that, while depressive symptoms decreased with nortriptyline medication and interpersonal therapy, bereavement intensity was not impacted on by either treatment modality. By contrast, other studies have identified more similarities than differences between bereavement-related depressions and MDD. For example, Kendler et al. (2008) compared large sub-sets of those with confirmed bereavement-related depression and confirmed depression following non-bereavement stressful life events. The two subsets did not differ by age at onset of major depression, number of prior episodes, duration of index episode, number of endorsed DSM “A criteria” or the proportion meeting criteria for “normal grief”. Research by Zisook and Kendler (2007) suggested that both individuals with bereavement-related depression and standard MDD responded favourably to antidepressant treatment and showed a similar trend toward recurring depressive episodes. This led the authors to conclude that, as bereavement-related depression resembled typical MDD, it should therefore be considered a form of MDD. Many limitations emerge from the lack of identified or agreed on parameters that might distinguish between a grief response and a depressive episode, particularly when they co-occur—and which may reflect the bereaved individual already having an independent depressive state, being vulnerable to depressive episodes or because the context of the bereavement and its consequences are depressogenic.
The DSM-IV duration criterion specified for the “normal” grief response (i.e.,rtwo months) is alone not a reliable indicator as to when normal grief has developed into pathological grief or represents an MDD episode. In fact, research has demonstrated that differentiating bereavement-related depressions from true MDD cases cannot be reliably determined by time alone until approximately one year following the loss (Wakefield et al., 2011) and when only 16% will be depressed (Zisook & Shuchter, 1991). Over that immediate loss period, clinicians and researchers require other valid and reliable guidelines for distinguishing between a grief reaction and a depressive condition—and it is here that phenomenological distinction may provide key information. Such disparate findings argue again for a phenomenological approach to differentiating grief and depression before examining for clinical differentiation in more pristinely defined comparison groups. We reported a quantitative analysis within a sample of 200 outpatient and community participants (Parker et al., 2015) and now report qualitative analyses of the same sample. Sample characteristics (i.e. there being clinical and non-clinical sub-sets) allowed us to also determine if clinical status might be salient to definitional differences between depression and grief.
2. Methods We sought to interview those who had experienced either nonclinical or clinical depressive episodes so as to examine a broad spectrum of depressive experiences. Thus, we advertised for volunteers who were between the ages of 18 and 65 years, fluent in both written and spoken English and prepared to take part in “an interview about sadness and depression” or who would describe themselves as never having “experienced depression”. Exclusion criteria were memory or cognitive deficits which would disallow participation in an interview, primary schizophrenia or other nonaffective psychotic disorder and current psychosis. Participants were recruited via newspaper and web advertisements as well as placing flyers and posters in the Depression Clinic at the Black Dog Institute, Sydney. In order to assist participants in identifying and distinguishing between different emotional experiences, and to ensure that all participants were referring to the same emotional constructs, definitions were provided at the beginning of the interview for (i) a depressed mood state, (ii) sadness, (iii) grief and (iv) stress. A “depressed mood state” was positioned as “feeling both depressed and experiencing a drop in self-esteem or self-worth, perhaps following being taken down a peg, unfairly criticised or bullied, or sometimes even coming out of the blue without a trigger”. “Sadness” involved “feeling downhearted or sorrowful (but not experiencing any distinct drop in self-esteem or self-worth) when experiencing some rather temporary ‘loss’ (e.g. a partner going overseas for an extended period and being missed; leaving your family to move overseas; your sporting team loses when you had all your hopes in them winning)”. “Grief” involved “feeling heartache, distress and the anguish of loss but without any drop in self-esteem or self-worth when a painful and seemingly permanent break in a social bond is experienced (e.g. the death of a partner, relative or even a favoured pet)”. “Stress” involved “feeling stressed, insecure, fearful and unsettled but again without any distinct drop in self-esteem or self-worth (e.g. loss of a passport or running out of money or accommodation while overseas; being unable to meet necessary requirements at work or at school and which are likely to have painful consequences).” At interview, only participants who affirmed having ever experienced a depressed mood state episode were later asked “did it feel different to grief?” and, if affirmed, were asked to describe how their experience of depression differed from grief. Participants who judged there to be no difference were also asked to elaborate. Classification of clinical or non-clinical depressive episodes was made according to DSM-IV criteria imbedded into the research
G. Parker et al. / Journal of Affective Disorders 176 (2015) 43–47
interview, rather than recruitment source (i.e., community or clinicbased setting) or previous treatment history. Written informed consent was provided by each participant and the study was approved by the University of New South Wales Human Research Ethics Committee. 2.1. Data analysis The qualitative responses of sample members were sorted into themes using NVIVO (QSR International Pty Ltd. Version 10, 2012) and which undertakes a text search to generate word frequency, tree maps and code data according to themes or “nodes”, and with data later coded in the Statistical Package for Social Sciences (IBM Corp, 2011) to quantify response frequencies.
3. Results 3.1. Demographic variables The mean age of the total sample was 47.7 years (SD ¼13.2) and with 83% female. The sample was somewhat more likely to be educated to a Bachelor degree level or higher (56%), with 32% employed full-time and 26% part-time. Approximately one-third of the sample were married (31%) and with 27% of the sample having never been married. 3.2. Clinical characteristics Of the 153 participants who acknowledged having experienced a depressed state, 87% reported that it differed from grief, with only 13% reporting that the two states were similar. Of the total sample, 125 participants met DSM-IV criteria for a lifetime episode of major depression, while the remaining 28 had experienced nonclinical depressive states. Seventy-four of the clinical group (59%) met DSM-IV criteria for a melancholic depression, with an additional 21 participants (17%) receiving a diagnosis of a bipolar I or II disorder. During the interview, 82% of the sample explicitly reported experiencing grief in response to at least one of 16 stressful life events examined. Our analyses were then limited to those affirming differences between depression and grief. 3.3. Qualitative responses Nine principal categorical themes were identified for the whole sample. Results are presented firstly for the clinical group and then considered for the smaller non-clinical group in terms of their prevalence in being nominated. The first category (nominated by 24.0%) involved depression (compared to grief) weighting a mood state where they felt helpless, hopeless, and that the depression was beyond their control and endless. Helplessness and lack of control extracts in describing depression included: “A feeling of helplessness”; “Nothing could help it”; “When I'm grieving I feel like I can do something to help myself. When I'm depressed I can't do anything about it”; “In grief I had a handle on the process without getting lost. In depression, normal coping mechanisms didn't even touch the sides”; “Totally different. When you're depressed you just can't get out of it”; “Depression was more a feeling of inability.” “Hopelessness” was either nominated directly or via synonyms, such as “No light at the end of the tunnel”; “Not seeing that it will get better”. Examples of feeling that the situation was “endless” included statements that the depression was “unfocussed and endless”; that “everything was dark and there was no end to it”; and that while “grief wears off. This wasn't wearing off”. Depression engendering a loss of control sense
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was expressed directly or contrasted with grief—“Grief is heartache but easier to control than depression”. The second category (generated by 15.2%) captured self-esteem and self-worth being compromised when depressed but not when grieving. For example, with depression, “My self-worth just completely disappeared. I lost confidence”; “Loss of self-esteem and selfworth - made me question myself”; “Drop in self-esteem was very extreme, felt worthless, that nobody cared and I had no friends”; “Grief for me is losing something, whether it's a partner or my friend who dies. Depression was different, it impacted my ego and my selfesteem”; “With grief, you don't feel worthless”; “The self-worth thing teases out the difference”. Others addressed this theme nondirectly. For example, “I thought I didn't deserve to be loved”. The third theme (nominated by 13.6%) positioned depression as internal, while grief was externally orientated. For example: (Depression is) “More internal; I blamed myself a lot”; “Depression is internalised”; “I was feeling sorry for myself, with grief you're really feeling sorry for others”; “Grief is all about the other person and missing them. With depression - internalise, feeling worthless, selfcritical”; “Grief is about someone, depression is about yourself”. The fourth category (nominated by 13.6%) captured severity, with responses indicating that depression was experienced as “more severe” than grief. For instance: “It was worse than grief. I've felt grief that's all consuming but I could function, I could superficially do things”; “It was more paralysing”; “More intense; “More profound”; “Stopped going to work and felt I couldn't go on, couldn't cope with life anymore. When grieving I still continued on with work, seeking the company of friends but was still sad”. The fifth domain (nominated by 8.8% of participants) captured depression as involving a greater stress component (and perhaps sadness) but without a primary feeling of loss. For example: “It was born of frustration rather than loss”; “I was just really stressed but I didn't have any feeling of loss”; “It was stressful as well. When somebody dies you can put them on a pedestal. When someone is just out of your life there are other issues”; “Grief involves more sadness. (Depression) was a feeling of more stress rather than sadness”; “Real stress component”. The sixth domain (nominated by 10.4%) positioned grief as a natural part of life, whereas the experience of depression was effectively “unexpected”. For example: “Grief I can rationalise, it's the natural progression to lose a parent. You know you're going to miss them whereas this episode I didn't know what was going to happen or how I would react to it”; “The depressive mood state was unexpected”; “Grief, I think you know is a normal part of life”; “Grief is a natural part of life”; “Grief is a natural response that has its journey. You can learn to manage it”; “In grief…there's something really natural about it”; “Grief is a universal experience. Death is a reality”. The seventh domain (10.4%) captured a judgment that, in contrast to grief, there was no clear reason or explanation for their depression. For example: “The depression was unfocussed, nothing to pinpoint”; “Depression - no reason, no outlet. Don't understand why you are sad”; “It felt unexplained”; “It was out of the blue, sudden. How did I get here?”; “Grief you can identify with the cause, it's tangible”; “With grief you know exactly why you feel that way”; “I don't know if you can always explain why you're depressed”. The eighth theme (9.6%) captured respondents experiencing more physical symptoms in depressive states. For example: “It felt like such a heavy cloak that you're just absolutely suffocating, covered and weighed down and there is no light everything is just dark”; “Grief is nothing compared to depression. I was curled up in ball. You lose peripheral vision, lights not as bright”; “When I'm depressed I have very physical symptoms. I slow down, I can't think clearly”; “Progressed from an emotional reaction to a more chemical reaction. Goes beyond emotional feeling of sadness, grief, to my not being able
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to function. More notably physical than emotional”; “I couldn't think clearly. I would try but my brain didn't want to work.” Lastly, 10.4% of participants (of whom 5.8% had reported that their experience of depression and grief as the same) described depression as involving elements of grief. For instance, “I was definitely in a very dark place but I was grieving too”; “The grief was I've lost my wife, my kids, my house, my dog, but it was depression because I lost those things because I didn't care for them”; “Well it had the symptoms of grief-teary, sadness and then the symptoms of depression as well”. “There's grief in it because (since retiring) you miss the people”; “Maybe it was the grief of losing all the status and money I'd worked hard for. That was grief, to lose it all”; “The depression followed the same stages of grief (anger, denial etc)”. The subset of 28 non-clinical participants primarily considered depression to be more severe than grief (17.9%), and weighted by feelings of helplessness and hopelessness (14.3%). They referred to stress as part of their depressive experience (14.3%) and observed self-esteem to be lowered during depressive states (14.3%) but with some grief aspects in their experience of depression (14.3%). The remaining categories identified in the clinical sample (i.e., depression involving physical symptoms; depression emerging without a clear cause; an internal focus in depression versus an external focus; grief as a natural part of life) were less frequently reported. The key differences and similarities between depression and grief as identified by the total sample are represented in Fig. 1 with the figure graphing the extent to which the differing constructs were judged in terms of their varying differential potential and, for sadness and a sense of loss, their commonality.
4. Discussion Study limitations are first noted. Our provision of descriptions of grief, depression, sadness and stress at the beginning of the interview—while designed to assist participants in identifying relevant experiences—may have shaped or biased findings by prompting participants to recall those particular aspects of their episodes. However, this is likely to only be true for the emphasis placed on a lowering of self-esteem during depressive experiences and not during grief. That is, at the experiential level, participants provided varied responses and extended upon the defined characteristics of depression and grief by offering several additional discriminating factors - as summarised below. Secondly, our analyses were weighted to those who had experienced substantive clinical depressive episodes (i.e., 82% of the sample met DSM-IV criteria for either unipolar depressive
episode/s or a bipolar disorder) and there were comparatively few who reported experiencing normative depressive episodes (18%). Hence the total sample was heterogeneous, while comparative analyses of the clinical and non-clinical participants were limited by disproportionate sample sizes. Similarly, depressive reactions were generally viewed as more severe than grief. This may reflect us principally studying those with a clinical depressive state—and a differing severity emphasis might have emerged if we had sought to recruit those primarily experiencing grief. In addition, participants were asked the qualitative question (i.e., “Did it [the depression] feel different to grief?”) if they reported having experienced a depressed mood state, while an experience of grief was not a prerequisite for answering the question. During the interview, 82% of the sample explicitly reported experiencing grief in response to at least one of 16 stressful life events. For the remaining 18% of the sample, it is unclear to what extent they had experienced grief (or not) so as to compare to their episode of depression. Thus, it is possible that a proportion of the sample may not have had a significant personal experience with grief and therefore answered “no” to the above question, answered theoretically, or with a bias toward their experience of depression being more profound. Furthermore, the interview relied on retrospective self-reporting of emotional episodes, and the data are therefore subject to memory retrieval ability and recollection biases. Moreover, the majority of participants volunteering for the study were female (83%). It is unclear to what extent gender influenced the nature of responses and whether results would vary significantly with a predominantly male or gender-balanced sample. To summarise the present findings, our study sought to identify qualitative points of phenomenological distinction between grief and depressive states as perceived by those who had experienced clinical and those experiencing more “normative” depressive states. Eighty-seven per cent of the total sample experiencing depressive mood states reported experiencing depression as different from grief. Any grief experienced by those who were depressed was largely viewed as a consequence of the depressive symptoms (i.e., losses caused by depressive impairments). Interestingly, participants who reported similarities between depression and grief likened the two states following non-bereavement related losses (e.g., loss of “things”, including employment and financial status), suggesting that non-bereavement related losses are more likely to act as a trigger for clinical depression (i.e., MDD), while the mood difficulties associated with bereavement states are considered to be qualitatively different. In those reporting grief as differing from depression, when asked to elaborate on differences, respondents judged grief as more “natural” and to be expected, with a clear cause identified (i.e., the loss), having
Depression Helpless & hopeless Endless & beyond control Focus is internal Lowered self-esteem Physical symptoms More stressful More severe Often unexpected & inexplicable Leads to secondary losses
Loss Sadness
Grief Natural & expected part of life Focus is external Coping strategies are more effective Still able to function Loss as the clear cause of symptoms
Fig. 1. The independence and interdependence of depressive and grief states as described by clinical and non-clinical participants.
G. Parker et al. / Journal of Affective Disorders 176 (2015) 43–47
an external focus (i.e. loss of the other) rather than—in their experience of depression—there being an internal focus of reduced self-esteem, feelings of worthlessness and a loss of control, for a clear cause to be less likely, to appear “endless”, to be more severe and stressful than grief and to be accompanied by the presence of physical symptoms. Participants who had experienced non-clinical depression were less likely to report their depression as involving physical symptoms, occurring without a clear cause, having more of an internal than an external focus, or position grief (but not depression) as a natural aspect of life. Our results are consistent with the study reported by Mojtabai (2011) in indicating that, when compared to depression, an episode of grief is less likely to involve impairment in functioning and feelings of worthlessness, but proceeded beyond such studies in identifying a number of other additional constructs, an issue now examined. The differences between depression and grief offered by the clinical group may have been accounted for by the high proportion of participants who had experienced melancholic depressive episodes, and where ascriptions (Parker and Hadzi-Pavlovic, 1996) include episodes sometimes occurring without any distinct antecedent cause (i.e., more endogenous), to be more severe and to have a “corporeal” tone with the depressed individual observing physical symptoms or the depression being experienced as a “weighing down” or “slowing down” phenomenon. If a valid interpretation, it is one with important implications, in suggesting that differences might need to be approached at two differing levels. Thus, only a small set of features may differentiate at the base level a normative depressive mood from normative grief (i.e. lowered self-esteem, feelings of worthlessness). However, other features may differentiate clinical depression from grief—with such differentiating features being integral to the depressive sub-type (e.g. melancholic or non-melancholic depression) rather than to depression per se. If such a tiered model operates across the “world” of depressive experiences it might be expected to also operate for grief states. Thus, normative grief may possess certain phenomenological components and define the base state but “pathological grief” may differ at a second level (with parameters including severity, duration, attribution and clinical features). In essence, each domain may involve obligatory phenomenologically defining features and facultative ones that reside at the pathological as against the normative level. The question as to how best to differentiate grief and depression is therefore likely to produce confounded results if the two are compared at differing levels (e.g. normative grief vs clinical depression) and helps to explain the quite contrasting findings from the empirical literature—and with some noted in the Section 1. Such a two-tiered model is worthy of development, with current study findings suggesting some phenomenological constructs for further evaluation, while findings are worthy of consideration by
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ICD-11 and future DSM committees seeking to distinguish depression and grief.
Role of funding source This study was supported by an NHMRC program grant (1037196). The NHMRC did not participate in the study design, nor in the data collection and analysis process, or in any phase of the manuscript preparation.
Conflict of interest Nothing to declare.
Acknowledgements This study was funded by an National Health and Medical Research Council, Australia Program Grant (1037196). We thank Georgie McClure for data entry.
References Clayton, P.J., Halikas, J.A., Maurice, W.I., 1972. The depression of widowhood. Br. J. Psychiatry 120, 71–77. Clayton, P.J., 1990. Bereavement and depression. J. Clin. Psychiatry 51, 34–40. Freud, S., 1917. Mourning and melancholia. Standard edition. 14, 1957–1961. IBM Corp, 2011. IBM SPSS Statistics for Windows. IBM Corp., Armonk, NY (Version 20.0). Kendler, K.S., Myers, J., Zisook, S., 2008. Does bereavement-related major depression differ from major depression associated with other stressful life events? Am. J. Psychiatry 165, 1449–1455. Maj, M., 2012. Bereavement-related depression in the DSM-5 and ICD-11. World Psychiatry 11, 1–2. Mojtabai, R., 2011. Bereavement-related depressive episodes: characteristics, 3-year course, and implications for the DSM-5. Arch. Gen. Psychiatry 68, 920–928. QSR International Pty Ltd. Version 10NVivo qualitative data analysis software, 2012. Parker, G., Paterson, A., Hadzi-Pavlovic, D., 2015. Emotional response patterns of depression, grief, sadness and stress to differing life events: a quantitative analysis. J. Affect. Disord. 175, 229–232. Parker, G., 2013. Opening Pandora’s box: how DSM-5 is coming to grief. Acta Psychiatr. Scand. 128, 88–91. Parker, G., Hadzi-Pavlovic, D., 1996. Melancholia: A Disorder of Movement and Mood. Cambridge University Press, New York. Reynolds, C.F., Miller, M.D., Pasternak, R.E., Frank, E., Perel, J.M., Cornes, C., et al., 1999. Treatment of bereavement-related major depressive episodes in later life: a controlled study of acute and continuation treatment with nortriptyline and interpersonal psychotherapy. Am. J. Psychiatry 156, 202–208. Shear, M.K., 2012. Grief and mourning gone awry: pathway and course of complicated grief. Dialogues Clin. Neurosci. 14, 119–128. Wakefield, J.C., First, M.B., 2012. Validity of the bereavement exclusion to major depression: does the empirical evidence support the proposal to eliminate the exclusion in DSM-5? World Psychiatry 11, 3–10. Wakefield, J.C., Schmitz, M.F., Baer, J.C., 2011. Did narrowing the major depression bereavement exclusion from DSM-III-R to DSM-IV increase validity? Evidence from the NCS. J. Nerv. Ment. Dis. 199, 66–73. Wakefield, J.C., 2013. The DSM-5 debate over the bereavement exclusion: psychiatric diagnosis and the future of empirically supported treatment. Clin. Psychol. Rev. 33, 825–845. Zisook, S., Kendler, K.S., 2007. Is bereavement-related depression different than non-bereavement-related depression? Psychol. Med. 37, 779–794. Zisook, S., Shuchter, S.R., 1991. Depression through the first year after the death of a spouse. Am. J. Psychiatry 148, 1346–1352.
Contents lists available at ScienceDirect
Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Research report
Clinical features distinguishing grief from depressive episodes: A qualitative analysis Gordon Parker a,b,n, Stacey McCraw a,b, Amelia Paterson a,b a b
School of Psychiatry, University of New South Wales, Sydney, Australia Black Dog Institute, Sydney, Australia
art ic l e i nf o
a b s t r a c t
Article history: Received 4 December 2014 Received in revised form 30 January 2015 Accepted 31 January 2015 Available online 7 February 2015
Background: The independence or interdependence of grief and major depression has been keenly argued in relation to recent DSM definitions and encouraged the current study. Methods: We report a phenomenological study seeking to identify the experiential and phenomenological differences between depression and grief as judged qualitatively by those who had experienced clinical (n ¼125) or non-clinical depressive states (n ¼ 28). Results: Analyses involving the whole sample indicated that, in contrast to grief, depression involved feelings of hopelessness and helplessness, being endless and was associated with a lack of control, having an internal self-focus impacting on self-esteem, being more severe and stressful, being marked by physical symptoms and often lacking a justifiable cause. Grief was distinguished from depression by the individual viewing their experience as natural and to be expected, a consequence of a loss, and with an external focus (i.e. the loss of the other). Some identified differences may have reflected the impact of depressive “type” (e.g. melancholia) rather than depression per se, and argue for a two-tiered model differentiating normative depressive and grief states at their base level and then “clinical” depressive and ‘pathological’ grief states by their associated clinical features. Limitations: Comparative analyses between the clinical and non-clinical groups were limited by the latter sub-set being few in number. The provision of definitions may have shaped subjects' nominated differentiating features. Conclusion: The study identified a distinct number of phenomenological and clinical differences between grief and depression and few shared features, but more importantly, argued for the development of a two-tiered model defining both base states and clinical expressions. & 2015 Elsevier B.V. All rights reserved.
Keywords: Grief Depression Assessment Diagnosis Qualitative
1. Introduction In this report we pursue the phenomenological distinction of depression and grief. As summarised by Shear (2012), grief's hallmarks are yearning and sadness which emerge from the loss of the “other” and with self-esteem generally preserved, and in contrast to depression where the person views their own self as empty or impoverished —as differentiated by Freud (1917). A similar distinction is provided in a DSM-5 sub-script (p 161), where it is noted that the predominant affect in grief involves “feelings of emptiness and loss” while, in depression, it is a “persistent depressed mood and the inability to anticipate happiness or pleasure”. Further, the sub-script states that the preoccupying thought content in grief involves “memories of the
n Correspondence to: Black Dog Institute, Prince of Wales Hospital, Randwick 2031, Sydney, Australia. E-mail address: [email protected] (G. Parker).
http://dx.doi.org/10.1016/j.jad.2015.01.063 0165-0327/& 2015 Elsevier B.V. All rights reserved.
deceased” rather than the “self-critical or pessimistic ruminations” integral to depression, and that self-esteem is generally preserved in grief whereas in major depression “feelings of worthlessness and selfloathing are common”. Differentiation is nevertheless often difficult as individuals and patients may not define their emotional states quite so pristinely. Further, the two states may co-occur, making their formal differentiation even more difficult. Definitional and differentiation issues between grief and clinical depression have been wrestled with since DSM-III introduced the “major depressive disorder” (MDD) category, and with researchers and clinicians subsequently raising concerns that an episode of grief could manifest symptoms making an individual eligible for a MDD diagnosis (e.g., Clayton, 1990; Zisook and Shuchter, 1991). During the initial stages of an acute grief reaction, it might be expected that the presence of distinctive “depressive” symptoms would not be interpreted as necessarily indicative of a depressive disorder if the bereavement context is taken into consideration. The DSM-IV formalised this
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nuance by including bereavement as an exclusion criterion for a major depressive episode—unless depressive symptoms persist for more than two months after the bereavement, are gravid and uncharacteristic of normal grieving (e.g., suicidal ideation, psychotic symptoms, or psychomotor retardation) or are associated with marked functional impairment. This exclusion criterion sought to avoid pathologising normal grief responses in the estimated onethird to one-quarter of individuals who would otherwise meet MDD criteria if assessed within two months of bereavement (Zisook and Shuchter, 1991; Clayton et al., 1972). The DSM-5 notes that responses to a significant loss such as bereavement “may resemble a depressive episode”, with overlapping symptoms usually including insomnia, appetite and weight loss, rumination about the loss, and intense sadness, therefore somewhat blurring distinction. In contrast to DSM-IV, DSM-5 does not state that responses to significant loss are exclusion criteria for major depressive episodes, but instead instructs practitioners to “exercise clinical judgement” in determining whether a grief response is accompanied by a MDD depressive episode, and by evaluating what would be expected to be the “normal response to a significant loss” given the individual's history and consideration of cultural norms. DSM-5 also allows that “responses to a significant loss” are not limited to grief caused by a break in a social bond (bereavement), but also lists financial ruin, losses from a natural disaster, serious medical illness and disability as exemplars, and risks some conjoining of the two states. The controversy generated by the DSM-5 classification (Maj, 2012; Parker, 2013; Wakefield, 2013; Wakefield and First, 2012) contributed to undertaking the present study, which seeks to identify phenomenological points of distinction. Previous study findings have variably reported substantive and minimal differences between the two states. For example, one US longitudinal epidemiological study reported that episodes of grief were prototypically different from standard major depressive episodes in being less likely to involve impairment in role functioning, fatigue, hypersomnia, feelings of worthlessness or suicide ideation (Mojtabai, 2011). In addition, bereaved individuals did not demonstrate an increased risk to future depressive episodes and were less likely to need medication or psychological therapy for depression and so differed from those with nonbereavement-related major depressive episodes. In relation to differing treatment responses, Reynolds et al. (1999) reported that, while depressive symptoms decreased with nortriptyline medication and interpersonal therapy, bereavement intensity was not impacted on by either treatment modality. By contrast, other studies have identified more similarities than differences between bereavement-related depressions and MDD. For example, Kendler et al. (2008) compared large sub-sets of those with confirmed bereavement-related depression and confirmed depression following non-bereavement stressful life events. The two subsets did not differ by age at onset of major depression, number of prior episodes, duration of index episode, number of endorsed DSM “A criteria” or the proportion meeting criteria for “normal grief”. Research by Zisook and Kendler (2007) suggested that both individuals with bereavement-related depression and standard MDD responded favourably to antidepressant treatment and showed a similar trend toward recurring depressive episodes. This led the authors to conclude that, as bereavement-related depression resembled typical MDD, it should therefore be considered a form of MDD. Many limitations emerge from the lack of identified or agreed on parameters that might distinguish between a grief response and a depressive episode, particularly when they co-occur—and which may reflect the bereaved individual already having an independent depressive state, being vulnerable to depressive episodes or because the context of the bereavement and its consequences are depressogenic.
The DSM-IV duration criterion specified for the “normal” grief response (i.e.,rtwo months) is alone not a reliable indicator as to when normal grief has developed into pathological grief or represents an MDD episode. In fact, research has demonstrated that differentiating bereavement-related depressions from true MDD cases cannot be reliably determined by time alone until approximately one year following the loss (Wakefield et al., 2011) and when only 16% will be depressed (Zisook & Shuchter, 1991). Over that immediate loss period, clinicians and researchers require other valid and reliable guidelines for distinguishing between a grief reaction and a depressive condition—and it is here that phenomenological distinction may provide key information. Such disparate findings argue again for a phenomenological approach to differentiating grief and depression before examining for clinical differentiation in more pristinely defined comparison groups. We reported a quantitative analysis within a sample of 200 outpatient and community participants (Parker et al., 2015) and now report qualitative analyses of the same sample. Sample characteristics (i.e. there being clinical and non-clinical sub-sets) allowed us to also determine if clinical status might be salient to definitional differences between depression and grief.
2. Methods We sought to interview those who had experienced either nonclinical or clinical depressive episodes so as to examine a broad spectrum of depressive experiences. Thus, we advertised for volunteers who were between the ages of 18 and 65 years, fluent in both written and spoken English and prepared to take part in “an interview about sadness and depression” or who would describe themselves as never having “experienced depression”. Exclusion criteria were memory or cognitive deficits which would disallow participation in an interview, primary schizophrenia or other nonaffective psychotic disorder and current psychosis. Participants were recruited via newspaper and web advertisements as well as placing flyers and posters in the Depression Clinic at the Black Dog Institute, Sydney. In order to assist participants in identifying and distinguishing between different emotional experiences, and to ensure that all participants were referring to the same emotional constructs, definitions were provided at the beginning of the interview for (i) a depressed mood state, (ii) sadness, (iii) grief and (iv) stress. A “depressed mood state” was positioned as “feeling both depressed and experiencing a drop in self-esteem or self-worth, perhaps following being taken down a peg, unfairly criticised or bullied, or sometimes even coming out of the blue without a trigger”. “Sadness” involved “feeling downhearted or sorrowful (but not experiencing any distinct drop in self-esteem or self-worth) when experiencing some rather temporary ‘loss’ (e.g. a partner going overseas for an extended period and being missed; leaving your family to move overseas; your sporting team loses when you had all your hopes in them winning)”. “Grief” involved “feeling heartache, distress and the anguish of loss but without any drop in self-esteem or self-worth when a painful and seemingly permanent break in a social bond is experienced (e.g. the death of a partner, relative or even a favoured pet)”. “Stress” involved “feeling stressed, insecure, fearful and unsettled but again without any distinct drop in self-esteem or self-worth (e.g. loss of a passport or running out of money or accommodation while overseas; being unable to meet necessary requirements at work or at school and which are likely to have painful consequences).” At interview, only participants who affirmed having ever experienced a depressed mood state episode were later asked “did it feel different to grief?” and, if affirmed, were asked to describe how their experience of depression differed from grief. Participants who judged there to be no difference were also asked to elaborate. Classification of clinical or non-clinical depressive episodes was made according to DSM-IV criteria imbedded into the research
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interview, rather than recruitment source (i.e., community or clinicbased setting) or previous treatment history. Written informed consent was provided by each participant and the study was approved by the University of New South Wales Human Research Ethics Committee. 2.1. Data analysis The qualitative responses of sample members were sorted into themes using NVIVO (QSR International Pty Ltd. Version 10, 2012) and which undertakes a text search to generate word frequency, tree maps and code data according to themes or “nodes”, and with data later coded in the Statistical Package for Social Sciences (IBM Corp, 2011) to quantify response frequencies.
3. Results 3.1. Demographic variables The mean age of the total sample was 47.7 years (SD ¼13.2) and with 83% female. The sample was somewhat more likely to be educated to a Bachelor degree level or higher (56%), with 32% employed full-time and 26% part-time. Approximately one-third of the sample were married (31%) and with 27% of the sample having never been married. 3.2. Clinical characteristics Of the 153 participants who acknowledged having experienced a depressed state, 87% reported that it differed from grief, with only 13% reporting that the two states were similar. Of the total sample, 125 participants met DSM-IV criteria for a lifetime episode of major depression, while the remaining 28 had experienced nonclinical depressive states. Seventy-four of the clinical group (59%) met DSM-IV criteria for a melancholic depression, with an additional 21 participants (17%) receiving a diagnosis of a bipolar I or II disorder. During the interview, 82% of the sample explicitly reported experiencing grief in response to at least one of 16 stressful life events examined. Our analyses were then limited to those affirming differences between depression and grief. 3.3. Qualitative responses Nine principal categorical themes were identified for the whole sample. Results are presented firstly for the clinical group and then considered for the smaller non-clinical group in terms of their prevalence in being nominated. The first category (nominated by 24.0%) involved depression (compared to grief) weighting a mood state where they felt helpless, hopeless, and that the depression was beyond their control and endless. Helplessness and lack of control extracts in describing depression included: “A feeling of helplessness”; “Nothing could help it”; “When I'm grieving I feel like I can do something to help myself. When I'm depressed I can't do anything about it”; “In grief I had a handle on the process without getting lost. In depression, normal coping mechanisms didn't even touch the sides”; “Totally different. When you're depressed you just can't get out of it”; “Depression was more a feeling of inability.” “Hopelessness” was either nominated directly or via synonyms, such as “No light at the end of the tunnel”; “Not seeing that it will get better”. Examples of feeling that the situation was “endless” included statements that the depression was “unfocussed and endless”; that “everything was dark and there was no end to it”; and that while “grief wears off. This wasn't wearing off”. Depression engendering a loss of control sense
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was expressed directly or contrasted with grief—“Grief is heartache but easier to control than depression”. The second category (generated by 15.2%) captured self-esteem and self-worth being compromised when depressed but not when grieving. For example, with depression, “My self-worth just completely disappeared. I lost confidence”; “Loss of self-esteem and selfworth - made me question myself”; “Drop in self-esteem was very extreme, felt worthless, that nobody cared and I had no friends”; “Grief for me is losing something, whether it's a partner or my friend who dies. Depression was different, it impacted my ego and my selfesteem”; “With grief, you don't feel worthless”; “The self-worth thing teases out the difference”. Others addressed this theme nondirectly. For example, “I thought I didn't deserve to be loved”. The third theme (nominated by 13.6%) positioned depression as internal, while grief was externally orientated. For example: (Depression is) “More internal; I blamed myself a lot”; “Depression is internalised”; “I was feeling sorry for myself, with grief you're really feeling sorry for others”; “Grief is all about the other person and missing them. With depression - internalise, feeling worthless, selfcritical”; “Grief is about someone, depression is about yourself”. The fourth category (nominated by 13.6%) captured severity, with responses indicating that depression was experienced as “more severe” than grief. For instance: “It was worse than grief. I've felt grief that's all consuming but I could function, I could superficially do things”; “It was more paralysing”; “More intense; “More profound”; “Stopped going to work and felt I couldn't go on, couldn't cope with life anymore. When grieving I still continued on with work, seeking the company of friends but was still sad”. The fifth domain (nominated by 8.8% of participants) captured depression as involving a greater stress component (and perhaps sadness) but without a primary feeling of loss. For example: “It was born of frustration rather than loss”; “I was just really stressed but I didn't have any feeling of loss”; “It was stressful as well. When somebody dies you can put them on a pedestal. When someone is just out of your life there are other issues”; “Grief involves more sadness. (Depression) was a feeling of more stress rather than sadness”; “Real stress component”. The sixth domain (nominated by 10.4%) positioned grief as a natural part of life, whereas the experience of depression was effectively “unexpected”. For example: “Grief I can rationalise, it's the natural progression to lose a parent. You know you're going to miss them whereas this episode I didn't know what was going to happen or how I would react to it”; “The depressive mood state was unexpected”; “Grief, I think you know is a normal part of life”; “Grief is a natural part of life”; “Grief is a natural response that has its journey. You can learn to manage it”; “In grief…there's something really natural about it”; “Grief is a universal experience. Death is a reality”. The seventh domain (10.4%) captured a judgment that, in contrast to grief, there was no clear reason or explanation for their depression. For example: “The depression was unfocussed, nothing to pinpoint”; “Depression - no reason, no outlet. Don't understand why you are sad”; “It felt unexplained”; “It was out of the blue, sudden. How did I get here?”; “Grief you can identify with the cause, it's tangible”; “With grief you know exactly why you feel that way”; “I don't know if you can always explain why you're depressed”. The eighth theme (9.6%) captured respondents experiencing more physical symptoms in depressive states. For example: “It felt like such a heavy cloak that you're just absolutely suffocating, covered and weighed down and there is no light everything is just dark”; “Grief is nothing compared to depression. I was curled up in ball. You lose peripheral vision, lights not as bright”; “When I'm depressed I have very physical symptoms. I slow down, I can't think clearly”; “Progressed from an emotional reaction to a more chemical reaction. Goes beyond emotional feeling of sadness, grief, to my not being able
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to function. More notably physical than emotional”; “I couldn't think clearly. I would try but my brain didn't want to work.” Lastly, 10.4% of participants (of whom 5.8% had reported that their experience of depression and grief as the same) described depression as involving elements of grief. For instance, “I was definitely in a very dark place but I was grieving too”; “The grief was I've lost my wife, my kids, my house, my dog, but it was depression because I lost those things because I didn't care for them”; “Well it had the symptoms of grief-teary, sadness and then the symptoms of depression as well”. “There's grief in it because (since retiring) you miss the people”; “Maybe it was the grief of losing all the status and money I'd worked hard for. That was grief, to lose it all”; “The depression followed the same stages of grief (anger, denial etc)”. The subset of 28 non-clinical participants primarily considered depression to be more severe than grief (17.9%), and weighted by feelings of helplessness and hopelessness (14.3%). They referred to stress as part of their depressive experience (14.3%) and observed self-esteem to be lowered during depressive states (14.3%) but with some grief aspects in their experience of depression (14.3%). The remaining categories identified in the clinical sample (i.e., depression involving physical symptoms; depression emerging without a clear cause; an internal focus in depression versus an external focus; grief as a natural part of life) were less frequently reported. The key differences and similarities between depression and grief as identified by the total sample are represented in Fig. 1 with the figure graphing the extent to which the differing constructs were judged in terms of their varying differential potential and, for sadness and a sense of loss, their commonality.
4. Discussion Study limitations are first noted. Our provision of descriptions of grief, depression, sadness and stress at the beginning of the interview—while designed to assist participants in identifying relevant experiences—may have shaped or biased findings by prompting participants to recall those particular aspects of their episodes. However, this is likely to only be true for the emphasis placed on a lowering of self-esteem during depressive experiences and not during grief. That is, at the experiential level, participants provided varied responses and extended upon the defined characteristics of depression and grief by offering several additional discriminating factors - as summarised below. Secondly, our analyses were weighted to those who had experienced substantive clinical depressive episodes (i.e., 82% of the sample met DSM-IV criteria for either unipolar depressive
episode/s or a bipolar disorder) and there were comparatively few who reported experiencing normative depressive episodes (18%). Hence the total sample was heterogeneous, while comparative analyses of the clinical and non-clinical participants were limited by disproportionate sample sizes. Similarly, depressive reactions were generally viewed as more severe than grief. This may reflect us principally studying those with a clinical depressive state—and a differing severity emphasis might have emerged if we had sought to recruit those primarily experiencing grief. In addition, participants were asked the qualitative question (i.e., “Did it [the depression] feel different to grief?”) if they reported having experienced a depressed mood state, while an experience of grief was not a prerequisite for answering the question. During the interview, 82% of the sample explicitly reported experiencing grief in response to at least one of 16 stressful life events. For the remaining 18% of the sample, it is unclear to what extent they had experienced grief (or not) so as to compare to their episode of depression. Thus, it is possible that a proportion of the sample may not have had a significant personal experience with grief and therefore answered “no” to the above question, answered theoretically, or with a bias toward their experience of depression being more profound. Furthermore, the interview relied on retrospective self-reporting of emotional episodes, and the data are therefore subject to memory retrieval ability and recollection biases. Moreover, the majority of participants volunteering for the study were female (83%). It is unclear to what extent gender influenced the nature of responses and whether results would vary significantly with a predominantly male or gender-balanced sample. To summarise the present findings, our study sought to identify qualitative points of phenomenological distinction between grief and depressive states as perceived by those who had experienced clinical and those experiencing more “normative” depressive states. Eighty-seven per cent of the total sample experiencing depressive mood states reported experiencing depression as different from grief. Any grief experienced by those who were depressed was largely viewed as a consequence of the depressive symptoms (i.e., losses caused by depressive impairments). Interestingly, participants who reported similarities between depression and grief likened the two states following non-bereavement related losses (e.g., loss of “things”, including employment and financial status), suggesting that non-bereavement related losses are more likely to act as a trigger for clinical depression (i.e., MDD), while the mood difficulties associated with bereavement states are considered to be qualitatively different. In those reporting grief as differing from depression, when asked to elaborate on differences, respondents judged grief as more “natural” and to be expected, with a clear cause identified (i.e., the loss), having
Depression Helpless & hopeless Endless & beyond control Focus is internal Lowered self-esteem Physical symptoms More stressful More severe Often unexpected & inexplicable Leads to secondary losses
Loss Sadness
Grief Natural & expected part of life Focus is external Coping strategies are more effective Still able to function Loss as the clear cause of symptoms
Fig. 1. The independence and interdependence of depressive and grief states as described by clinical and non-clinical participants.
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an external focus (i.e. loss of the other) rather than—in their experience of depression—there being an internal focus of reduced self-esteem, feelings of worthlessness and a loss of control, for a clear cause to be less likely, to appear “endless”, to be more severe and stressful than grief and to be accompanied by the presence of physical symptoms. Participants who had experienced non-clinical depression were less likely to report their depression as involving physical symptoms, occurring without a clear cause, having more of an internal than an external focus, or position grief (but not depression) as a natural aspect of life. Our results are consistent with the study reported by Mojtabai (2011) in indicating that, when compared to depression, an episode of grief is less likely to involve impairment in functioning and feelings of worthlessness, but proceeded beyond such studies in identifying a number of other additional constructs, an issue now examined. The differences between depression and grief offered by the clinical group may have been accounted for by the high proportion of participants who had experienced melancholic depressive episodes, and where ascriptions (Parker and Hadzi-Pavlovic, 1996) include episodes sometimes occurring without any distinct antecedent cause (i.e., more endogenous), to be more severe and to have a “corporeal” tone with the depressed individual observing physical symptoms or the depression being experienced as a “weighing down” or “slowing down” phenomenon. If a valid interpretation, it is one with important implications, in suggesting that differences might need to be approached at two differing levels. Thus, only a small set of features may differentiate at the base level a normative depressive mood from normative grief (i.e. lowered self-esteem, feelings of worthlessness). However, other features may differentiate clinical depression from grief—with such differentiating features being integral to the depressive sub-type (e.g. melancholic or non-melancholic depression) rather than to depression per se. If such a tiered model operates across the “world” of depressive experiences it might be expected to also operate for grief states. Thus, normative grief may possess certain phenomenological components and define the base state but “pathological grief” may differ at a second level (with parameters including severity, duration, attribution and clinical features). In essence, each domain may involve obligatory phenomenologically defining features and facultative ones that reside at the pathological as against the normative level. The question as to how best to differentiate grief and depression is therefore likely to produce confounded results if the two are compared at differing levels (e.g. normative grief vs clinical depression) and helps to explain the quite contrasting findings from the empirical literature—and with some noted in the Section 1. Such a two-tiered model is worthy of development, with current study findings suggesting some phenomenological constructs for further evaluation, while findings are worthy of consideration by
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ICD-11 and future DSM committees seeking to distinguish depression and grief.
Role of funding source This study was supported by an NHMRC program grant (1037196). The NHMRC did not participate in the study design, nor in the data collection and analysis process, or in any phase of the manuscript preparation.
Conflict of interest Nothing to declare.
Acknowledgements This study was funded by an National Health and Medical Research Council, Australia Program Grant (1037196). We thank Georgie McClure for data entry.
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