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

Bereavement Doesn't "Immunize" Against Depression

Dr Pies: Thanks to you both for these excellent descriptions.

One of the most controversial decisions the DSM-5 made was to drop the so-called "bereavement exclusion" when diagnosing an MDE. Essentially, the DSM-IV had instructed clinicians not to diagnose major depression within the first 2 months after the death of a loved one, unless certain putative markers of severity were present, such as suicidal ideation, marked functional impairment, psychomotor retardation, sense of worthlessness, or psychosis.

The DSM-5, in contrast, tells us that the subset of persons who meet the full symptom/duration/severity criteria for major depression within the first few weeks after bereavement should not be excluded from the set of all persons with major depression.To put it more simply: The DSM-5 recognizes that bereavement does not "immunize" the grieving person from major depression, and is in fact a frequent precipitant of major depression.[6]

Despite some guidance in the DSM-5 regarding the differences between grief and major depression, many clinicians remain puzzled or uncertain as to how the two are distinguished.

Sid, this is an area you have explored deeply. Can you give the primary practice physician, and psychiatrists as well, four or five key features that you look for when distinguishing grief from major depression, in the context of recent bereavement? And, then, Kathy, can you add a bit on how complicated grief differs from major depression?

Dr Zisook: The first step is to remember precisely what grief and major MDD represent. The death of a loved one almost always triggers grief; but, an exquisitely stressful and sometimes traumatic life event may also precipitate a number of adverse health consequences, including (but not limited to) MDD.

Grief is the normal, expected, generally adaptive psychological, biological, interpersonal, and social response to loss. MDD, on the other hand, is a serious, sometimes malignant, life-threatening, mental disorder marked by intense, persistent and pervasive sadness or anhedonia. MDD generally is a recurrent condition and often is quite chronic.

Thus, I would rephrase the question I was asked to discuss. The more meaningful question is not so much, "How can grief and MDD be differentiated?" as it is, "How can an MDE be diagnosed when it occurs in a recently bereaved person who is still actively grieving?" That can be a challenging and tricky clinical conundrum, even for the most experienced clinician.

The DSM-5 does a good job in helping clinicians to understand when grief may be complicated by a co-occurring MDE. In the footnote for the diagnostic criteria of an MDD, the DSM-5 notes:

Key issue: The predominant affect in grief that is not complicated by an MDE a sense of emptiness and loss. When there is also an MDE, persistent and pervasive depressed mood and the inability to anticipate happiness or pleasure predominate, even in the absence of reference to the deceased.

Nature of dysphoria: In grief that is not complicated by an MDE, the dysphoria tends to decrease in intensity over days to weeks and occurs in waves that are associated with thoughts or reminders of the deceased—so-called "pangs of grief." When an MDE intervenes, the dysphoria tends to be more persistent and not tied to specific thoughts or preoccupations.

Positive emotions: In grief, the pain may be accompanied by positive emotions, such as humor, relief, warmth, and even pleasure in the closeness with significant others. In contrast, when a MDE also is present, more pervasive unhappiness and misery are likely to leave no room for warmth, joy, or humor.

Preoccupations: Thoughts and memories of the deceased predominate in grief. When the grief is accompanied by a coexisting MDE, thoughts also are focused on oneself being bad, undeserving, or unworthy.

Self-esteem: In grief, self-esteem is generally preserved. When grief is accompanied by an MDE, thoughts of worthlessness and self-loathing also are common.

Consolability: Grieving individuals often feel supported and comforted by friends and relatives sharing time and conveying condolences. When an MDE intervenes, people are far less consolable or approachable.

Suicidal thoughts: In grief, thoughts of death or dying are generally focused on the deceased and possibly about joining them. In a bereaved person who is also suffering from an MDE, thoughts may be more focused on ending one's life because of feeling undeserving of life, feeling unable to withstand the seemingly unending torture of depression, and/or mistakenly believing that others would be better off without them.

Even with these guidelines, is not always easy to diagnose an MDE in the context of bereavement. It is clear that a symptom checklist is not enough. Rather, a more nuanced assessment, taking into account some of the features and phenomenology noted above, combined with the unique history, beliefs, and social/cultural dimensions of the person and their environment, must be weighed into the diagnostic process.

Sometimes it is useful to wait before making a definitive diagnosis. This is especially true in someone who does not have a previous history of MDD, and if symptoms are relatively mild and not life-threatening. When in doubt, past history and family history, as well as a tincture of time, may help inform clinical judgment and decisions.

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