Fast Fact and Concept #043: Is it Grief or Depression

2nd Edition

Author(s): VJ Periyakoil

Distinguishing between a dying patient’s normal grief and a major depression is a part of routine care for patients near the end-of-life. This Fast Fact will review the definitions and clinical features that distinguish these conditions.

DEFINITIONS

Preparatory (aka anticipatory) grief is the grief, "that the terminally ill patient has to undergo in order to prepare himself for his final separation from this world" 1. Features include rumination about the past, withdrawal from family/friends and periods of sadness, crying or anxiety. Preparatory Grief is a normal, not pathological, life cycle event.

Depression: Clinically significant depression among a population of dying patients may be somewhat more common (25-77%) 2 than in the general population. However, depression is not an inevitable part of the dying experience and is very treatable. Somatic symptoms (anorexia, weight changes, constipation etc) are often present as a part of the normal dying process and may not help to distinguish between preparatory grief and depression (See Fast Fact #7).Feelings of guilt, hopelessness, worthlessness, and suicidal ideation are the key factors that differentiate grief from depression; when in doubt, treat for depression. The following additional points are offered to help the clinician distinguish between preparatory grief and depression

DISTINGUISHING PREPARATORY GRIEF vs. DEPRESSION

Temporal Variation

A temporal variation of mood is normal in preparatory grief—a mixture of “good and bad days”. In contrast, persistent flat affect or dysphoria is characteristic of depression. Depression is a pathological state; patients may 'get stuck' in this state without treatment.

Self-Image

A disturbed self-esteem is not typically seen in grief while this is a common feature of depression; overwhelming and persistent feelings of worthlessness to others and of being a burden are common in depression. Distressing guilt in usually generalized to all facets of life in depression, while in grief, the guilt is focused around specific issues (e.g. not being able to attend a child’s wedding).

Hope

A grieving patient's hope shifts, but is not lost. (Hope may shift from a hope for cure to hope for life prolongation to hope for dying well). In contrast, the depressed patient will comment on feelings of hopelessness and helplessness.

Anhedonia

The ability to feel pleasure is not lost in preparatory grief. Note: grieving patients often need social interaction to help them through the grief process. Anhedonia is an important clue to underlying depression.

Response to Support

Social support helps provide the acceptance and assistance necessary for completion of grief work 3. While social interaction may be helpful in some depressed patients, it will typically not provide the assistance necessary to resolve depression.

Active Desire for an Early Death

An active desire for an early death is not typical of preparatory grief.A persistent, active desire for an early death in a patient, whose symptomatic and social needs have been reasonably met, is suggestive of clinical depression.

• Kubler-Ross E. On Death and Dying: 123-124; New York, NY:Simon and Schuster, 1997.
• EPEC Project Module 6: Anxiety, Delirium, Depression; AMA, 1999.
• Rando TA.: Grief, Dying, and Death. Clinical Interventions for the Caregiver. Research Press Company, Champaign, Illinois, 1984.
• Chochinov HM, et al. Desire for death in the terminally ill. Am J of Psychiatry, 1995;152:1185-91.
• Billings A and Block S. Depression. J Pall Care 1995; 11:48-54.2
• Block, SD., for the ACP-ASIM End-of-Life Care Consensus Panel. Assessing and managing depression in the terminally ill patient. Annals Intern Med 2000;132:209-218.
• Block SD. Perspectives on care at the close of life. Psychological
• considerations, growth, and transcendence at the end of life: the art of the possible. JAMA. 285(22):2898-905, 2001 Jun

Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007.  For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu

Copyright/ Referencing Information : Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Periyakoil, VJ. Fast Facts and Concepts #43: Is it grief or depression? August 2005, 2nd edition. End-of-Life / Palliative Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 6/2001; August 2005, 2nd edition

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): psychosocial and spiritual experience, psychiatric disorders

Specific Disease and Organ System Category(s): Psychiatric Disorders