A Closer Look at Diagnosing Grief vs Depression

Grief and depression are both associated with low mood and functional impairment that may wax and wane over hours, days, or longer periods of time. These problems may be associated with life events and may disrupt the person’s sleep, appetite, work, recreation, social relationships, and other important aspects of everyday life. Let’s examine grief and depression with an eye toward comparing them, and also look at the treatment of depression in the context of grief, and techniques to promote resolution of grief in the context of depression.

Major losses other than the loss of a life partner may trigger similar mood and behavioral responses that are regarded as normal. The intensity of the response is likely to reflect the severity of the loss. The loss of a child may trigger grief like bereavement. Rejection by a lover may include varying degrees of grief depending on the degree of attachment to the lover. Losses that trigger grief are not confined to the loss of a person. Loss of a valued pursuit is easily recognized as a real loss and a grief response is expected and thought of as normal, for example, the athlete who sustains a serious injury and can no longer compete at their previous high level or the writer who new novel is panned by critics and sells poorly. We can all understand such loss and the normality of the grief reactions that occur in response. Most of us could list several times in our lives when loss has triggered grief that we, and our close friends and family, regard as normal.

Depression. Depression seems to be a different matter. Yes, it can occur after an unfortunate event or loss, but it generally does not seem to follow a socially validated emotional path back to normality. The emotions seem out of proportion to the situation and to have a life of their own. The abnormal mood state, not a life event, seems to be the problem. A problematic mood without a socially acceptable reason and without a socially validated path to return to normality seems wrong. The unusual, dysfunctional mood seems to friends and family more like illness rather than an understandable reaction to life events. Medical science has described and classified various types of depression (ie, major depressive disorder, persistent depressive disorder, treatment-resistant depression, etc) and other dysfunctional mood states as illnesses (eg, bipolar depression), not normal reactions to a particular type of life event. To varying degrees, medical science has been able to reliably describe recurring patterns of dysfunctional moods, determine the biological cause of the dysfunction, and devise effective treatments. Thus, modern psychiatry follows the same methods that are used throughout modern scientific medicine.

Over the past 50 years, or so, as depression came to be recognized as an illness, many people have been concerned that the normal process of grief would be considered an illness. The first edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM) addressed this issue by saying that depression could not be diagnosed in the presence of grief until 6 or more months after the onset of grief. It was soon realized that position was proposing that grief somehow warded off depression. There was no reason to think that grief protected against depression. The best way to accommodate the normality of grief and depression was seen to be to allow a diagnosis of depression to be used in addition to the normal process of grief. The one exception is if the grief is substantially prolonged, the manual gives criteria allowing diagnosis of Prolonged Grief Disorder. This approach of allowing grief to be noted and a mood disorder to be concurrently diagnosed supports the current practice of providing needed counseling and social support to all individuals who are grieving, while simultaneously giving standard treatment for the mood disorder, which is usually medication.

The challenge for practitioners is to be able to easily use the often-complex criteria in clinical settings and clinical time restraints. This task has been simplified using symptom checklists that can assure accurate diagnoses more readily than trying to use a diagnostic manual in a busy clinic.

Let’s now look at several examples of seemingly complex patients to see how this diagnostic system is applied, and how therapeutics can address multiple problems.

Three Cases Involving Grief and/or Depression

Case 1: Jenny is a 60-year-old woman college teacher. Her husband Phil is receiving palliative care for cancer that has not responded to chemotherapy. After Phil’s death, Jenny sees her primary care physician (PCP) and reports transient thoughts of taking her own life without actual intent, decreased appetite, decreased energy, difficulty falling asleep, early morning awakening, difficulty concentrating on her teaching responsibilities, and poor appetite. She notes that she was treated as an outpatient for depression when she was 34 and again in her 40s. Each of these episodes responded to antidepressant medication. She dropped out of those treatments due to feeling improved.

Her PCP diagnoses recurrent major depressive disorder and notes bereavement and starts a low dose of the same antidepressant that Jenny took previously. At her 2-week follow-up visit, Jenny has minimal side effects, and the dose is increased to the usual therapeutic dose. Jenny begins counseling with a geropsychologist in the same clinic. Six months after her husband’s death she continues to grieve her husband; however, the depressive symptoms have largely resolved. She continues to take antidepressant medication and has regular follow-ups with her PCP and her psychologist. She has returned to teaching. She now lives in a retirement complex, where she has made a few new friends. She attends a weekly grief group, which she finds helpful.

Case 2: Alice is a 33-year-old married woman with 2 children, ages 3 and 5. She works long hours as a PCP, a career that has been her dream since elementary school. She is the only child of 2 successful physicians. Her husband works in finance, having cut back his hours and decreased his time on the golf course to spend more time caring for the children. During a routine gynecological visit, Alice tells the doctor that she takes little satisfaction from her medical practice. She is unhappy with her workdays, which include long hours, tedious documentation, little time for educational activities, and her list goes on. Alice says she is losing connection with her children and her husband. The doctor notes that Alice’s mood is somewhat low and irritable. Alice has no thoughts of self-harm.

Using a standard rating scale Alice’s doctor finds that her symptoms do not reach the severity required for a diagnosis of depression. The doctor notes the clear presence of grief due to Alice’s perceived loss of a successful medical career, and loss of her meaningful relationship with her husband and children. Alice accepts referral to a women’s “rebranding group.”

The social worker who leads the group assists the members in recognizing that career advancement is rarely linear these days. One cannot simply accept a junior post and expect to succeed by following a well-worn career path. Similarly, family success requires more nimble teamwork by husband and wife than in the past. “Rebranding” refers to the process of developing a new concept of one’s competencies and desires, at work, in the family, and in the wider social world. With time, Alice fashions a “new brand” in which she truly believes, and she can clearly articulate to others.

She allows herself to accept opportunities in line with the new brand, yet to put clear limits on how much of herself she gives to any one aspect of her plan. After a year, Alice’s grief is no longer troubling her. She, her husband, and her children are doing considerably better. After 2 years Alice’s grief is a thing of the past.

Case 3: Jerry is a 45-year-old gay male clothing salesman with a history of bipolar affective disorder. Jerry had 2 psychiatric hospitalizations at ages 24 and 27. During the second hospitalization, he started combined treatment with lithium carbonate and quetiapine. Since the second hospitalization, he had continued the same medications and had discontinued the use of alcohol. With that regimen, he had been reasonably stable, with consistent employment and a satisfying marriage to Martin.

This equilibrium was disrupted when Martin was driving home from a men’s chorus rehearsal in his small car when an intoxicated man driving a large pickup truck at high speed swerved into Martin’s lane, resulting in a head-on collision. Both airbags deployed; however, both men were killed in the accident.

The next day Jerry did not go to work, and his friends lost track of him. They found him a few days later in a casino 50 miles from home. He has been drinking heavily and appeared disheveled. He told his friends that he had heard all of them telling him that he should crash his car and die just like Martin. His friends reassured him of their good intentions, and Jerry accepted a ride to a hospital in his home city, where he was admitted to the psychiatric unit.

On examination in the hospital, Jerry continued to have a low mood and heard his friends’ voices telling him to join Martin by killing himself. He was tearful and said that he didn’t think he could go on living without Jerry.

The psychiatrist diagnosed an acute mixed episode of bipolar affective disorder (depressive and manic symptoms), with psychotic features, and alcohol abuse. It was noted that this psychotic episode was occurring in the context of acute bereavement.

He restarted quetiapine and lithium. He did not require treatment for alcohol withdrawal due to his rather short-term use of alcohol. He attended group therapy sessions on the unit. He transitioned to attending therapeutic groups for people who have both mental health and substance use problems. A nurse met separately with him to discuss his grief.

After 3.5 weeks, Jerry no longer met legal criteria for involuntary hospitalization, and he wanted to leave the hospital. He was discharged with plans to live in his previous apartment. He attended a gay men’s clubhouse program and psychiatric follow-up with his previous psychiatrist.

At his 5-year follow-up, he is doing well. He continues to take medication for bipolar disorder. He is not drinking. He has no hallucinations, no delusions, and no thoughts of self-harm. He volunteers at the clubhouse. He is working full time at his previous employment. He misses Martin and frequently visits his grave. He doubts that he will ever resume dating but says he doesn’t know for sure what the future may bring.

William Harwell Wilson, MD, graduated from Brown University in Providence, Rhode Island, with a bachelor’s degree in English, Phi Beta Kappa. He then attended the University of Pennsylvania in