Can grief morph into depression?

Last week, NPR's "Talk of the Nation" aired a show that explored the line between grief and depression. Although they are quite different, they look surprisingly alike. Panelist Dr. Michael Miller, editor of the Harvard Mental Health Letter and assistant professor of psychiatry at Harvard Medical School, said that with both grief and depression "People cry. They feel depressed. They're having trouble sleeping. They may not have an appetite. They may not feel like doing anything. They may not take pleasure in anything."

For years, the American Psychiatric Association has urged doctors not to diagnose major depression in individuals who have recently lost a loved one. In the Diagnostic and Statistical Manual of Mental Disorders, sometimes known as the psychiatrist's bible for diagnosing mental illness, grief is specifically listed as an exception to the diagnosis of clinical depression. The organization is now considering dropping that exclusion, raising the question: Is grieving ever pathological?

Prolonged grief

Just as dying is an inevitable part of the cycle of life, bereavement is a necessary aspect of living. There is no timeline for grief. In addition, cultural and circumstantial factors contribute to how people express and cope with it.

Today, advances in medicine allow many people with terminal illnesses to live years after diagnosis, as opposed to the days, weeks, or months of previous decades. As described in in our book Saying Goodbye: A Guide to Coping with a Loved One's Terminal Illness, we refer to the grieving process in these situations as "the new grief" because there is time for patients and their families to get their affairs in order, resolve family issues, and choose how to live during whatever time may remain. This type of grief differs from the sudden shock and chaos that often accompanies a sudden death, which often leaves loose ends loved ones must deal with, as well as any unfinished business they had with the deceased.

During a prolonged illness, or after a death, a community of family, friends, and coworkers often unites to provide ongoing support to those who are grieving. Supporters (professionals, friends, spiritual advisers, family) can help those who are grieving resume functioning, and gradually move on with their lives while maintaining the memory of the lost one.

That is one key difference with depression. People suffering from major depression tend to be isolated and feel disconnected from others, and may shun such support and assistance. People who don't get such support, or who avoid it, may be at greater risk for slipping into clinical depression during the grieving process.

Dr. Miller points out that for some people who have previously struggled with acknowledged or unacknowledged depression, the death of a significant other can be the catalyst that brings depression to the foreground. In such cases, professional treatment such as therapy and/or medication can be helpful. In the interviews we conducted while writing and researching Saying Goodbye, we learned that some people found antidepressant medication to be helpful for restoring sleep and appetite and "taking the edge off." Other people who tried medication stopped taking it because they felt as though their feelings were flattened, and that the medication interfered with their ability to grieve.

Recognizing depression in grief

Bereavement is not linear. It takes multiple forms at different times in one's life. It is influenced, among other things, by the strength of our attachment to the lost loved one and how central he or she was to our lives. Bereavement never really ends. It ebbs after a while, but can then emerge on birthdays and anniversaries, in certain places, or triggered by something like a special song.

If you are in the process of coping with the sudden death of a loved one, or the lengthy grieving process associated with terminal illness, here are a few suggestions:

• Expect to feel depressed. Loss of appetite, trouble sleeping, and sadness are all part of the normal grief process, and are best not interfered with.
• Expect grief to wax and wane over time. You may feel fine one day, only to slip back into deep grief the next day.
• Build and use a support network. Grieving individuals need others to talk to and to care for them — not just for a few days, but over an extended period of time. This is especially true for those people who are primary caretakers for a terminally ill loved one.
• If you experience thoughts of suicide, serious weight loss, or are unable to perform daily functions such as getting out of bed or going to work for more than an occasional day, consider seeking additional professional help.