When are we grieving too much? Distinguishing grief from depression.

According to a concept in psychology known as attachment theory, humans are motivated from birth to form close bonds with others throughout their life. These connections provide the basis for identity, security, and support.

In addition to being stressful, the loss of a loved one can feel like it suddenly robs a person of this foundation, thrusting them into a state of uncertainty. It can force them to drastically redefine priorities, adjust their lifestyles, and seek support in order to properly move on and restore balance in their lives.

While the period following bereavement is known to involve emotional, physical, and functional impairment, there is a fine line between the organic and healthy process of grieving and the clinical diagnosis of major depressive disorder (MDD), which requires intervention and treatment.

Grief is a normal, natural response to bereavement. While contrasting ideologies regarding expressions of grief exist, the classic Kübler-Ross model specifies that it occurs in five stages: denial, anger, bargaining, depression, and acceptance.

Regardless of the different models of grief, there are three predominant forms: acute grief, integrated grief, and complicated grief.

Acute grief occurs immediately following the loss of a loved one. People with acute grief often experience intense sadness, loneliness, and a yearning to be reunited with the deceased person. These periods of painful emotions occur in waves and are often interspersed with periods of positive feelings, thoughts, and memories of the loved one.

Symptoms associated with acute grief may include social withdrawal, disrupted sleep, appetite changes, distractibility, memory impairment, and even auditory or visual hallucinations. It is not uncommon for individuals with acute grief to wish they had died with, or instead of, the deceased individual; however, these thoughts typically pass with time.

In general, acute grief responses are time-limited and depend on factors such as the personality of the bereaved, the circumstances of the deceased, the relationship between the two, and culture.

Ideally, people transition from acute grief to integrated grief as they learn to cope with the loss of the deceased and the balance of their daily life becomes restored. People with integrated grief continue to think about their departed loved one. However, these negative waves of emotions and/or functional impairments become less intrusive as the consequences of death are fully accepted. While the grief response to losing a loved one is life-long, people with integrated grief are able to once again enjoy life and gain satisfaction from relationships and activities. With integrated grief, the symptoms associated with acute grief are no longer as disabling or preoccupying as before, and although there might be flareups of intense grief during periods of heightened stress—or occasions like anniversaries—these are normal, acute, and self-limited.

Complicated grief is a subtype of grief marked by a prolonged timeline and persistent symptoms. People with complicated grief often experience the debilitating symptoms associated with acute grief for at least six months following the loss. The progression of these symptoms is often intense and unabated, and interferes with function. People experiencing complicated grief often have difficulty accepting the circumstances involving the death of their loved one, or reject the idea of a fulfilling and enjoyable life without their loved one. People with complicated grief should seek their healthcare provider for therapy.

Depression is a mood disorder that requires intervention and treatment. Per the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), MDD is characterized by feelings of hopelessness or a loss of interest, with associated symptoms including changes in appetite, sleep patterns, energy levels, speed of movements, concentration, and suicidality for at least a two-week period.

While many of these symptoms overlap with acute grief, there are important distinctions. In both MDD and grief responses, people may experience feelings of sadness, loneliness, or guilt. In grief, these periods of intense emotion come in waves and are always tied with the loss of the loved one. In MDD, these feelings are prevalent and persistent.

As with acute grief, healthy grieving involves waves of negative thoughts with periods of positive memories or emotions. This oscillation in emotional range is absent in people with MDD.

In terms of suicidal thoughts, while people with grief may experience such thoughts, they are centered on the deceased – either wanting to join their loved one, or wishing they had died instead of that person. In MDD, suicidal ideation as an intention stems internally. In other words, it is related to negative thoughts of oneself, the world, and the future.

Sleep, loss of interest, and appetite changes are associated with both conditions. In grief, these disruptions often occur as a result of preoccupation with the deceased or adjusting to life without the deceased. However, in MDD, these changes are more nonspecific.

In summary, while tremendous overlap exists between the symptoms associated with grief and MDD, there are major distinctions between the two. The predominant theme that separates the two is that in any form of grief response, all of the negative symptoms are closely associated with bereavement, and the symptoms oscillate in severity, while in MDD, the negative symptoms are generalized and pervasive.

In other words, a bereaved individual experiencing “healthy” grief can imagine enjoying life once again if they can be reunited with their loved one. However, a person with MDD could never envision a hopeful future, even with this hypothetical.

Understanding the types of grief and where you may lie on the spectrum of bereavement response is essential for your health maintenance. Especially if you find yourself towards the spectrum of complicated grief or MDD, it is important to consult with your healthcare provider in order to receive treatment and therapy.

— Nikhil Anbarasan