Grief as a response to significant loss is normal. However, the mourning that occurs during periods of grief has features that overlap with depression and anxiety. This makes it occasionally confusing to distinguish one from the other and to know how to help patients heal appropriately.
In previous DSM versions, mental health professionals were to exclude bereavement if wishing to make the diagnosis of Major Depression. The current version, DSM V, allows for Major Depression to be diagnosed during a mourning period. So, how does one properly distinguish the cases of depression that occur during grief and treat them appropriately?
Insomnia, anxiety, intense sadness, poor focus, memory troubles and reduced appetite can present in both cases but in grief these symptoms should be time limited and lessen over time. While performance may be temporarily curtailed and even modestly impaired during a period of mourning, it should not be anticipated that the affected individual should experience a prolonged or excessive degree of dysfunction or emotional distress.
No two people experience grief in the same way and there is no fixed formula for how long it should take to moderate in its intensity or impact. To a considerable degree, the grief experience is culturally diverse, varying by ethnicity, religion, and age. Thus, our own understanding of cultural diversity is critical in assessing for symptoms that might be more bound by culture for some than others. Attention to the cultural profiles and encouraging patients to seek solace with family and friends can be quite important. But, regardless of culture, the trend for healthy grief is to show improvement over time with fewer bouts of sadness, anxiety and distress recurring over time.
Major Depression in the setting of grief appears to be more persistent and pervasive.1 Often the feelings of guilt a depressed person reports is not related to grief and reflect excessive remorse or conflict about other unrelated issues such as being highly conflicted or ambivalent about the relationship with the lost person or object.
Thoughts of worthlessness or even suicide may also become manifest with patients with underlying depression during their periods of grief and these are not common in grieving individuals who do not have underlying and co-occurring mood disorders.
It is highly unlikely for an otherwise healthy patient with grief to experience true psychosis. That said, they may experience and report hearing voices or seeing visions of the lost loved one(s) and this, unless severe, ought not trigger serious concern if the individual is otherwise managing their affairs appropriately. For many patients the “voices” and “visions” are comforting and supportive. As a provider it is important to contextualize the reports of unusual experiences within cultural norms for the patient in grief and with the emotional profile of the patient prior to the loss experience. Onset of ego-dystonic or bizarre psychotic thinking should not occur with grief experiences and such symptoms are only rarely associated with depressive illness except for those that are quite severe.
With normative grief experiences, supportive social engagement is often adequate but when an individual is struggling regaining their equilibrium, referral for psychotherapy (individual and group) is typically appropriate and recourse to prescribed medication, though on some occasions very brief (days not weeks) treatment of sleep disorders or anxiety may be appropriate. For most individuals experiencing a major loss, encouraging the person to take care of him/herself better and to attend to their needs for sleep, nutrition, and physical exercise and to seek social supports will helps them through the process.
If a patient meets diagnostic criteria for major depression antidepressants with sustained and disruptive symptomatology, it may be appropriate to seek psychiatric consultation and to prescribe antidepressant medication along with encouraging involvement in psychotherapy.
2.How Long Does Grief Last? The Grief Recovery Handbook, John James and Russel Friedman, 2017