1. Ferszt, Ginette G. RN, CS, CT, PHD * Associate Professor
  2. Leveillee, Mary RN, CS, MS * Assistant Clinical Professor

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GRIEF IS A NORMAL experience, often with intense emotional pain, that commonly follows a significant loss such as the death of a loved one. Most grieving people integrate their loss over time, but some are more vulnerable to developing a depressive disorder during this difficult period. Unfortunately, the grieving person, friends and family, and even healthcare professionals may attribute signs and symptoms of depression to grief, thereby prolonging suffering because he doesn't get help for a treatable disorder. Through careful and systematic assessment, you can recognize early signs and symptoms of depression in the context of bereavement and help identify someone who needs additional help.


Similar but different

Although everyone grieves differently, grief and depression share several common characteristics (see Identifying grief and depression). Both may include intense sadness, fatigue, sleep and appetite disturbances, low energy, loss of pleasure, and difficulty concentrating. The key difference is that a grieving person usually stays connected to others, periodically experiences pleasure, and continues functioning as he rebuilds his life. With depression, a connection with others and the ability to experience even brief periods of pleasure are generally missing. Sometimes people describe feeling as if they have fallen into a black hole and fear they may never climb out. Overwhelming emotions interfere with the ability to cope with everyday stressors.


Healthcare professionals may overlook the possibility that someone troubled by loss is suffering from depression. For example, if a widower sees his healthcare provider for fatigue and insomnia, the focus of care may be on treating the symptoms without exploring his sadness. Even some grief counselors may fail to recognize depression in someone who's grieving unless they're trained and have the clinical expertise to assess for a mood disorder.

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Red flags for depression

When problems such as fatigue, insomnia, and indecisiveness persist from 2 weeks to several months and impair the bereaved person's functioning, depression may be responsible. Other red flags include inability to experience enjoyment, a grim outlook for the future, and a persistent, uncharacteristic negative self-view. Inappropriate guilt and remorse may dominate the person's life. He may feel as if a veil or a wall separates him from others. Ironically, being with other people can reinforce feelings of separateness and aloneness.


If you suspect that a grieving patient is depressed, pay attention to how family and friends respond to his sadness. Typically, people willingly support someone who's grieving. If you sense a lack of support, consider if they're reacting to his ongoing depression. When their continued support doesn't help their loved one feel better, they may feel helpless and want to flee from his persistent negative view. Overwhelmed by emotions and unable to see any solution to suffering, he may consider suicide his only option to end the pain and lighten his family's burden.


History helps unravel the mystery

A history of trauma, accumulated losses, and concurrent stressors in someone experiencing grief increases his risk of depression. Obtain a detailed personal and family history, assessing for such risk factors as a parent's death at an early age, a history of childhood abuse, an eating disorder, and a family or personal history of mood disorders or alcoholism. Here are some ways to approach these sensitive topics.


Asking about family history. If you ask a patient whether anyone in his family has had depression or another psychiatric disorder, he may be reluctant to open up or may be unaware of such a diagnosis. Everyday terminology is less threatening and more likely to get a response. Ask, for example, "Do you remember any family member going through periods when he slept a lot, couldn't function in his daily life, and needed to have others care for him?"


Assessing for alcohol abuse. Scientific studies have found that depression and alcoholism often co-occur. When asking about family history, consider that relatives who abused alcohol also may have had undiagnosed depression. Ask the patient about his own use of drugs or alcohol, which could escalate depression and put him at greater risk for suicide.


Tallying stressors. Studies also show that bereavement may be more difficult in someone with accumulated losses or concurrent stressors. Ask your patient to describe past losses he's experienced, such as family deaths, divorce, assault, loss of a pet, and even possessions lost in a natural disaster. Find out when the losses occurred, how he dealt with them, whether other people supported him, and how. Then ask about current stressors in his life.


Listening to the language. When your patient describes his grief, does he focus on himself, with talk of self-blame or past wrongs? Does he express feelings of overwhelming guilt and an increasing sense of hopelessness? All these factors point to depression rather than grief alone, and he should be assessed by a mental health professional.


Getting help

Teaching patients about the similarities and differences between grief and depression is an important nursing strategy. Describing the physical causes of depression may help decrease the stigma that can be associated with mental illness. Offering your patient a resource list of community mental health centers, social workers, psychiatric clinical nurse specialists, and psychologists may help him seek counseling.


If a mental health provider assesses your patient and diagnoses depression, she may prescribe medication to manage the symptoms. Some grief therapists believe that such intervention can interfere with grieving, but poor sleep or high anxiety levels compromise anyone's ability to cope. Medication may give your patient the energy needed in the grieving process.


By exploring your patient's emotional response to loss, you seize the opportunity to assess him for a serious mood disorder. This nursing action can help relieve the unnecessary suffering depression can cause.


Selected references


Ferszt G, Leveillee M. How do you distinguish between grief and depression? Nursing. 2006;36(9):60-61.


Stroebe MS, Hansson RO, Stroebe W, Schut H, eds. Handbook of Bereavement Research and Practice. Washington, DC: American Psychological Association; 2008.


Varcarolis EM, Benner Carson V, Shoemaker N. Foundations of Psychiatric Mental Health Nursing: A Clinical Approach. 5th ed. Philadelphia, PA: WB Saunders; 2006.


Worden JW. Grief Counseling and Grief Therapy. A Handbook for the Mental Health Practitioner. 4th ed. New York: Springer Publishing Co.; 2008.