Grief is a natural process experienced after any type of loss. It can encompass a broad range of symptoms but often follows a seven-stage process.1,2 Depression may seem to come unexpectedly for some, while others often experience precipitating events reminding them of their loss before the onset of their depression.3 In some cases, grief can contribute to developing a depressive disorder outside of the grieving process, becoming a co-occurring grief disorder.
What Is Grief?
Grief is an emotional wound associated with a loss, with the most intense symptoms usually experienced after the death of a loved one.4 Grief can spur feelings of sadness, be associated with trauma, and lead to depression. When the grief is uncomplicated, a person can generally obtain a sense of acceptance and relief within six months after the loss.5
The seven stages of grief are:2
- Shock & Denial: In the shock and denial stage of grief, the individual consciously or subconsciously denies the loss to avoid pain.
- Pain & Guilt: As the initial shock wears off, the individual is confronted with reality and starts to experience excruciating pain.
- Anger & Bargaining: When the individual unleashes intense feelings that have been kept at bay. The anger can be directed at a specific person, higher power, or oneself.
- Depression & Loneliness: When the individual takes time to reflect and realize the loss’s true magnitude. Some experience despairing sadness when they recognize that the loss is permanent.
- The Upward Turn: As the depression starts to uplift, the individual attempts to adjust to a new life.
- Reconstruction & Working Through: When the individual forms a new identity and develops a plan to deal with the aftermath following the loss (e.g., making financial arrangements, returning to full professional capacity, etc.).
- Acceptance & Hope: When the individual accepts the loss and finds a newly redefined life. Acceptance does not free the individuals from pain but gives them a sense of relief and closure.
When experiencing grief, both children and adults can develop depressive symptoms, especially if the loss is significant such as the loss of a child, loss of a pet, losing a grandparent, or a miscarriage.
Some other examples of grief outside of losing a loved one include:1
- Major health changes
- Employment changes or depression after retirement
- Holiday seasons
- Perinatal loss
- Empty nest syndrome
- Loss of identity and values
- Ambiguous loss
- Anticipatory grief
- Grieving a celebrity death
Difference Between Grief and Depression
Sadness can be a part of both conditions, but there are distinct differences between grief and depression. Grief is a natural and universal emotion in reaction to a loss, while there are many different causes for depression, including genetic causes. Usually the intensity of grief subsides with time. If depression is left untreated it can get worse and threaten quality of life, and with suicide ideation it can become life-threatening.
Duration of Symptoms
There is no specific time frame associated with grief. The way grief manifests will be related to the closeness and nature of the relationship with the person who is lost. Grief experts agree that there is no specific time frame associated with grief or a specific stage. It is not linear and people can skip a stage and return to another more than once. There is no right or wrong way to grieve. It is a personal and unique experience for each individual.
Depression can range from mild to severe. The severity of symptoms directly impacts how long it lasts. Major depressive disorder is the most serious type of depression, with symptoms that can last for 6 months or longer. Persistent depressive disorder is a more long-term type of depression. With this diagnosis the intensity of symptoms can change for brief times but can remain for years. In cases of diagnosed depression where symptoms do not improve people may need outside help from a mental health professional to overcome it. Depression can be treated with therapy and also medication.
Ability to Function Day-to-Day
When a person is grieving they need time to adapt to a “new normal” in the absence of a loved one who was depended on for emotional support and to help with daily challenges. People sometimes want to avoid others who don’t know what to say or how to respond to their loss. Especially in the midst of early grief, there are very intense feelings of sadness, loneliness, and sometimes anger and guilt. This overload of emotions can cause cognitive impairments resulting in difficulty with memory, concentration, and an ability to focus (often called grief brain). As people move forward through grief the intensity and frequency of these feelings will subside and eventually go away. Moments when you can function well and feel happy without guilt will happen with time.
It is very hard to function when a person is experiencing severe depression, and each day may be a struggle just to get out of bed. Simple daily tasks like eating, dressing and other self care tasks may be abandoned or feel overwhelming. There are feelings of hopelessness and helplessness that make it difficult to try to do anything. People often isolate themselves because it takes energy to be around other people. Concentration can be hard impeding the ability to work. Increased irritability is also a common symptom with serious depression. Depressive symptoms can be alleviated with the proper treatment and support.
Acceptance of Support
With both grief and depression there may be a reluctance to ask for support. This is especially true for disenfranchised grief. Examples of disfranchised grief may be a loss due to suicide or a drug overdose. It might be not wanting to be judged about the nature of a loss and how you are coping with it. It is difficult to discuss this type of loss because of preconceived beliefs people have about it that may inhibit your ability to candidly discuss feelings.
People that are very depressed may be apathetic. As depression lingers they may have increased feelings of worthlessness and low self esteem. They may not feel deserving of support. There may be false beliefs there is nothing anyone can do to help with their depression.
There is a temptation with both grief and depression to suffer silently and perhaps self isolate. When feelings from grief and depression are not addressed they can worsen. In both scenarios reaching out for support is the best way to begin to cope and start dealing with the debilitating symptoms. Try to reach out to friends, family, a doctor, a spiritual mentor, or therapist to get needed help. Chat rooms online or in-person support groups are also safe spaces where support is available in dealing with grief and depression. Show yourself kindness and empathy. Tell yourself you are deserving of support to help overcome your grief and depression.
Identifying Depression as Part of Grief
Depression and grief can still coexist and interact.7 The main difference is that grief tends to decrease over time, whereas depression is more pervasive and persistent.7 Nonetheless, they do share many similarities.
When depression is a part of grief, the following symptoms may pursue:8
- Changes in appetite, weight loss, or gain unrelated to dieting
- Trouble sleeping (insomnia) or sleeping too much (hypersomnia)
- Intense sorrow, pain, and rumination
- Sadness, guilt, and self-blame
- Loss of energy or increased fatigue
- Feeling worthless or helpless
- Difficulty concentrating, thinking, or making decisions
- Isolation from others and withdrawal from social activities
Depression & Prolonged Grief
Prolonged grief disorder (PGD) was added as an official diagnosis in the DSM-5, with the term “prolonged grief” used to describe overwhelming grief that does not get better with time.9 In some cases, the impairments caused by prolonged grief may intensify. In general, any loss might result in prolonged grief; however, violent or unexpected death and traumatic loss can increase the risk factors for PGD. Depression related to PGD comes from a deep longing and fixation for the deceased individual.10
Depression & Complicated Grief
Complicated grief is PGD when it has not been officially diagnosed by a mental health professional. When grief symptoms persist for more than six months, the individual is viewed as having complicated grief. In addition to other risk factors, complicated grief may also develop from the lack of closure due to resolved sadness and trauma.11
Depression & Disenfranchised Grief
Disenfranchised grief, also known as hidden grief, describes losses that cannot be publicly acknowledged or mourned through traditional means. Social opportunities provide a framework for people to express their grief when a loss occurs. These same standards may also prohibit individuals from being able to grieve certain aspects of their lives when they experience a loss due to social stigma.12 Depression can stem from the inability to naturally move through the stages of grief or the lack of support offered to the afflicted individuals.
What Can Cause Co-Occurring Grief & Depression?
When people experience prolonged or complicated grief, they likely have increased symptoms and a chance of developing mental health conditions. The worsening of the mental health condition can lead to the onset of depression and a phenomenon known as grief brain. In these cases, the brain is overloaded with sadness, loneliness, and other unproductive feelings that negatively impact the individual’s memory, concentration, and cognition.13 Some individuals are affected by depressive disorders related to grief, while others are not due to variations in genetic predispositions and other factors such as support and resiliency.
How Depression Complicates Healing From Grief
The two primary characteristics of depression are loss of interest and persistent low mood, among other symptoms. People struggling with depression typically lack the energy and motivation to perform tasks that can alleviate their symptoms. For example, grief-focused therapy is an excellent service because it provides guidance and support. Still, depressive symptoms might prevent the person from wanting or being able to seek out that resource.
Depression can complicate the healing process of grief in other ways, such as:
- Avoidance behavior
- Compulsive behaviors in the hopes of finding an escape
- Minimizing feelings as depression rather than grief
- Substance use disorders
Coping Skills for Grief & Depression
There are various ways to cope with grief and loss and coinciding depression without a professional’s help. The overarching understanding is that the individual should feel better as they progress through the grief stages and arrive at a point of relief and acceptance within six months. Complicated grief occurs when the symptoms persist longer than six months, and it is highly recommended that the individual seek out mental health treatment at this point.
Here are six coping skills to help improve depressive symptoms and resolve grief:
1. Acknowledge Positive & Negative Feelings
Someone must be willing to acknowledge their positive and negative feelings. It is common for people to shy away from challenging emotions such as anger, sadness, and fear with the apprehension of being rejected or being perceived as weak by others. When feelings are denied, the individual inadvertently invalidates their pain, which disrupts the grieving process.
2. Allow Time to Experience Pain & Loss
Grief is a natural and inevitable part of human existence; nonetheless, it can sometimes be painful and undesirable. An individual might feel the need to fast-track their grieving process. Intentional actions that force acceptance and the feelings of being “ok” can be counterproductive and exacerbates the symptoms. The individual needs to be mindful while grieving, no matter how difficult it might be.
3. Confide In Trusted People
Having someone to confide in during the grieving process can be helpful, especially if there are a lot of difficult emotions and thoughts to express. The goal is to find someone you can trust with confidential information, as only some are good candidates for emotional support. Being able to share the grief with another person can provide a sense of relief and smooth the healing process.
4. Express Feelings Openly
Expressing a full range of feelings (e.g., shock, pain, guilt, anger, sadness, hope, and relief) is critical to progress through grief. Journaling is a great alternative to help with emotional exploration and expression if someone has difficulty sharing their feelings aloud. Grief journal prompts provide guidance for someone unfamiliar with this process.
5. Find Grief or Bereavement Support Groups
Grief or bereavement support groups are an excellent way to connect with others who have gone through or are going through the same experience. The shared experience can help the individual not feel alone. Another benefit is getting to know someone who is further along in the grieving process, which enables the individual to experience a sense of hope. Finding online group therapy and support groups can be helpful, as you might be able to find a support group with people going through a similar experience.
6. Conduct Grief Rituals
Grief rituals are designated times to mourn. These activities can help a person honor the loss and facilitate the healing process.
Here are some examples of grief rituals:4
- Reviewing cherished memories
- Making a scrapbook about the event or the individual
- Drawing, painting, sculpting
- Making a collage
- Watching a movie or listening to music related to the loss
- Going to places that hold significance
- Running or supporting a charity
- Buying flowers or planting flowers
- Creating a ritual of yearly remembrance
What Should I Do If My Grief Won’t Go Away?
If your grief does not go away, it gets worse, or symptoms are harming your ability to function or are negatively impacting relationships, it is time to reach out to a mental health professional. Do not wait until you feel totally debilitated to reach out for help. The sooner symptoms are dealt with the quicker they will diminish and you can find eventual relief. If you have a doctor you know and trust that is a good place to start. A mental health therapist can help you clarify the source of your symptoms and offer guidance on ways you can learn how to cope. Find a therapist who specializes in grief work. You can find a therapist in your area by using an online therapist directory where you can search by specialty and insurance coverage.
Treatment for Grief and Depression
Depression is a complex illness, and the person with it can benefit from consulting with a professional well trained on treatments for depression. In most cases, mild to moderate depression can go away independently. On the other hand, severe or clinical depressive symptoms might require medication in conjunction with psychotherapy for long-term treatment when self-help techniques are not working.
Grief therapy can help the individual cope with the loss more effectively than self-help techniques.14 Professionals such as licensed therapists, psychologists, counselors, or psychiatrists can provide insights and guidance for those struggling with depression or grief symptoms. It is inaccurate to assume that one modality would be a good fit for everyone seeking depression therapy because each person has different needs and expectations. Choosing a therapist, counselor, or psychiatrist that meets your exact needs will require research but can be done through an online therapist directory or by asking your primary care provider for a referral.
Some common types of psychotherapy used to treat depression and grief include:
- Cognitive Behavioral Therapy (CBT): CBT is an evidence-based approach with years of research on its efficacy as a treatment modality. CBT assists individuals in exploring their inner thought processes and the underlining negative core beliefs that led to unhealthy behaviors and emotions in the past.15
- Acceptance and Commitment Therapy (ACT): ACT is a modality that combines both elements of behavior therapy and mindfulness approach. ACT helps individuals identify their values and learn to accept new experiences without letting adverse circumstances influence their actions and choices.15
- Eye Movement Desensitization and Reprocessing (EMDR): EMDR is another evidence-based approach that is highly productive in treating traumas and other mental health disorders, including depression. EMDR protocols utilize bilateral stimulation to help individuals process stuck traumas, which leads to cognitive integration and peaceful resolution.16
- Mindfulness-Based Cognitive Therapy (MBCT): MBCT is a form of CBT that incorporates aspects of meditation and mindfulness into its practice. MBCT teaches individuals grounding skills they can utilize when triggered by negative thoughts.17
When depression and complicated grief require medication support, antidepressants can help decrease symptoms by increasing levels of certain brain chemicals (e.g., dopamine, serotonin, and norepinephrine).2 Psychotropic medications require a prescription for antidepressants from a psychiatrist or other medical professionals who can help the individual identify the risks and benefits.
Some common types of medication for depression and grief include:
- Selective Serotonin Reuptake Inhibitors (SSRIs)*
- Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)*
- Tricyclic & Tetracyclic Antidepressants (TCAs)*
- Monoamine Oxidase Inhibitors (MAOIs)*
*These medications have a black box warning, the most severe kind of warning from the FDA for the risk of suicidal thoughts and behaviors in certain people. Before starting any of these medications, you should talk with your doctor about these risks.
Grief can be a painful and sorrowful process, especially if the loss is significant, like the death of a loved one. Under normal circumstances, most humans naturally go through their grieving process without complications or can manage their symptoms by utilizing self-help coping skills. Nonetheless, there are instances where the individuals would need additional support from a counselor or a psychiatrist to help with treatment. When grief becomes complicated, it can cause the individual to become stuck and unable to move forward toward acceptance. Another consequence of complicated grief is the onset of depression. If depression and grief symptoms are exacerbated, the individual must seek professional help as soon as possible to minimize adverse long-term effects on their mental health.