COMMENTARY

Distinguishing Grief, Complicated Grief, and Depression

Ronald W. Pies, MD; M. Katherine Shear, MD; Sidney Zisook, MD

Disclosures

December 26, 2014

In This Article

Editor's Note: Depression, grief, and complicated grief can be difficult to distinguish from one another. However, a study[1] recently published in JAMA Psychiatry—the first randomized trial to explore the treatment of complicated grief (CG) in an elderly population—emphasizes how important it is to recognize when grieving patients are also suffering from comorbid psychopathology, so that appropriate care can be delivered. Medscape contributor Ronald W. Pies, MD, professor of psychiatry at SUNY Upstate Medical University in Syracuse, New York, recently moderated an email discussion between lead author M. Katherine Shear, MD, program director for Columbia University's Center for Complicated Grief, and Sidney Zisook, MD, distinguished professor and director, Department of Psychiatry at the University of California San Diego, La Jolla, California, on what complicated grief is, how to treat it, and how to distinguish it from grief and depression.

Depression vs Grief vs Complicated Grief

Dr Pies: I'm delighted to have my colleagues, Dr Sid Zisook and Dr Kathy Shear, join me in a discussion of grief, depression, and some of the controversies surrounding these topics.

Sid and Kathy, as we know, the concepts of grief, complicated grief, and depression are sometimes tough for clinicians to sort out. This is especially true in the context of recent bereavement: that is, following the death of a loved one or significant other. Sometimes our colleagues in primary care—and in psychiatry, too—find it hard to tell whether a patient who has just suffered the death of a loved one is experiencing grief or depression, both, or neither. Unfortunately, these terms are often used in confusing ways, both in the popular media and in some of the professional literature.

So, to get the ball rolling, can we provide some brief, basic definitions or descriptions of the terms "grief," "complicated grief," and "depression"?

Dr Zisook: "Depression" is a broadly used term for the self-limiting and generally benign everyday blues that we all experience from time to time, as well as a catch-all for a group of serious, often quite malignant mental illnesses, herein grouped under the rubric "major depression." The latter, in turn, encompasses a group of important clinical conditions: major depressive episodes (MDEs) seen in bipolar mood disorders, major depressive disorder (MDD, or "unipolar" depression); and persistent depressive disorder, which may or may not have fewer or less intense symptoms than MDD, but is marked by its persistence (at least 2 years' duration).

Each of these clinical conditions are themselves heterogeneous, comprising a spectrum of severity from relatively mild to quite severe. And they may (but not necessarily) be associated with anxious, mixed, melancholic, atypical, or psychotic features, and may be in full bloom or in partial or full remission.

To help clinicians differentiate the nonclinical type of depression—sadness or the blues—from the clinical conditions, it is important to remember that none of these clinical conditions should be diagnosed absent three key characteristics:

Severity (at least five of the characteristic symptoms);

Duration (most of the day, nearly every day, for at least 2 weeks); and

Pathology (clinically significant distress or impairment).

In keeping with the acknowledgment in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), that classification of mental disorders is a work in progress, and that the current classification system is intended to serve as a "practical, functional, and flexible guide for organizing information that can aid in the accurate diagnosis and treatment of mental disorders," we favor also adding clinical judgment and caution to the diagnostic menu.

Thus, if a person meets criteria for one of the clinical conditions, but it is a first episode and relatively mild (eg, only five or six symptoms are met and these do not include feelings of worthlessness or suicidal ideation), brief (less than 1 or 2 months) and only minimally impairing, it may make sense to delay making a formal or definitive diagnosis while more information is gathered and a tincture of time is allowed its due.

Just as it is important not to overdiagnose the blues of everyday life as major depression, it is every bit as vital not to overlook major depression when it is there. No disorder is more painful or has a more profound effect on the way a person relates to others, feels about themselves or their worth as a human being, functions in everyday activities, or maintains hope of a better future.

Here, I think a quote from Infinite Jest, by David Foster Wallace, beautifully describes severe major depression:

It is a level of psychic pain wholly incompatible with human life as we know it. It is a sense of radical and thoroughgoing evil not just as a feature but as the essence of conscious existence. It is a sense of poisoning that pervades the self at the self's most elementary levels. It is a nausea of the cells and soul.

Sometimes major depression seems to occur out of the blue, with no warning; sometimes its onset is gradual and almost unnoticeable; and sometimes it seems to be brought on, or intensified, by stressful life events, such as the death of a loved one. When that happens, a reverberating cycle sets in: The depression increases the stress, intensifies the grief, and may even interfere with grief's resolution, setting the stage for a condition we call "complicated grief."

Whether or not triggered by adversity, major depression tends to be both chronic (at least 20% of all episodes last 2 or more years) and recurrent (at least 90% of acute episodes recur). In its more severe forms, the sufferer is withdrawn and inconsolable, and ongoing life may feel untenable. In short, it is a miserable state.

President Abraham Lincoln said of being depressed:

I am now the most miserable man living. If what I feel were equally distributed to the whole human family, there would not be one cheerful face on the earth. Whether I shall ever be better I cannot tell; I awfully forebode I shall not. To remain as I am is impossible; I must die or be better, it appears to me.

In such a state, it is no surprise that thoughts of death or dying are core features of major depression and that suicide is an all-too-frequent tragic outcome, especially when the depression is unrecognized or untreated.

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