Research Synopsis: Distinguishing Grief and Depression

An excellent article -- "Grief and Bereavement: What Psychiatrists Need to Know" -- is available from World Psychiatry on PubMed Central.* The authors, Sidney Zisook and Katherine Shear, summarize the importance of their topic by noting that

After completing their education and formal training, psychiatrists may not be fully prepared to handle some of the most common clinical challenges they will face in practice. Diagnosing and treating complicated grief and bereavement related major depression will undoubtedly rank high on the list of such challenges. Both conditions overlap with symptoms found in ordinary, uncomplicated grief, and often are written off as "normal" with the assumption that time, strength of character, and the natural support system will heal.

The article claims clear distinctions among "uncomplicated (normal) grief," "complicated grief," and "grief-related major depression," and whether or not one agrees with all of the authors' conclusions, their classification is explained with careful detail and supported by research.

While observing that there is "no simple answer" to the question of defining normal grief and that "grief is different for every person and every loss," the authors cogently outline the characteristics of the experience:

♦  Grief is not a state, but rather a process.
♦  The grief process typically proceeds in fits and starts [i.e., the pain of loss comes and goes].
♦  The spectrum of emotional, cognitive, social and behavioral disruptions of grief is broad, ranging from barely noticeable alterations to profound anguish and dysfunction.
♦  For most people grief is never fully completed ... [There is] acute grief that occurs in the early aftermath of a death ... [and] a later form of grief, integrated or abiding grief, in which the deceased is easily called to mind, often with associated sadness and longing [emphasis added].
♦  Grief is not only about separation from the person who died, but about finding new and meaningful ways of continuing the relationship with the deceased.

Complicated grief "results from the failure to transition from acute to integrated grief" and "occurs in about 10% of bereaved people ... As a result, acute grief is prolonged, perhaps indefinitely." Its hallmarks are

♦  separation distress (recurrent pangs of painful emotions, with intense yearning and longing for the deceased, and preoccupation with thoughts of the loved one) [and]
♦  traumatic distress (sense of disbelief regarding the death; anger and bitterness; distressing, intrusive thoughts related to the death; and pronounced avoidance of reminders of the painful loss).

Zisook and Shear aptly capture the essence of people's experience of complicated grief:

They may believe that their life is over and that the intense pain they constantly endure will never cease. Alternatively, there are grievers who do not want the grief to end, as they feel it is all that is left of the relationship with their loved one.

To unravel the concept of grief-related major depression, the authors begin by pointing out that the major studies related to the topic

have found roughly similar results, demonstrating a high frequency of depressive symptoms that diminish in frequency and intensity over time, but that may continue to occur at greater frequency than in non-bereaved controls for years after the death.

They argue that the distinction between grief and major depression is clear, describing it as follows:

♦  Grief is a complex experience in which positive emotions are experienced alongside negative ones. As time passes, the intense, sad emotions that typically come in waves are spread further apart ... Furthermore, grief is a fluctuating state with individual variability, in which cognitive and behavioral adjustments are progressively made until the bereaved can hold the deceased in a comfortable place in his or her memory and a satisfying life can be resumed.
♦  In contrast, major depression tends to be more pervasive and is characterized by significant difficulty in experiencing self-validating and positive feelings. Major depression is composed of a recognizable and stable cluster of debilitating symptoms, accompanied by a protracted, enduring low mood. It tends to be persistent and associated with poor work and social functioning, pathological immunological function, and other neurobiological changes ...

The summary offered here omits almost entirely any discussion of diagnosis and treatment, which the authors cover in-depth, so please read the complete article for information about the clinical implications of what is outlined above.

* PubMed Central is a free digital archive of biomedical and life sciences journal literature at the U.S. National Institutes of Health, developed and managed by NIH's National Center for Biotechnology Information in the National Library of Medicine. Although online access to articles is available, publishers' copyrights are in force.