Grief, bereavement and depression

Written by Dr PJ Marshall, MB ChB MRCPysch and Clare Atkinson, research specialist registrar in psychiatry

What is grief?

This is a term that describes all the feelings, thoughts and behaviour that someone goes through after bereavement.

What is bereavement?

This is a term that can be used to describe any event that includes loss, so this could mean losing your job or the death of someone you know. In this article it refers to the death of a person.

There is no right way of coping with a death; people respond to a loss in their own individual way. The way a person responds is partly dependent on their relationship with the deceased, but it also depends on their own personality and upbringing. In particular, holidays and anniversaries serve as reminders of the loss, and many people experience a severe worsening of their grief at these times.

Debate still continues as to what normal grief consists of and whether it is distinct from depression. It is very common for people to have symptoms that are often used to diagnose depression after bereavement. It is less common for people to experience a depressive illness and require treatment for this.

A psychological understanding of grief

People need strong affectionate bonds with other people for their emotional wellbeing, and they try hard to maintain these ties. Loss through death permanently breaks this bond.

Grief can be seen as a person's struggle to maintain the emotional bond, while simultaneously experiencing the reality of loss. 'Grief work' is the process that a mourner needs to complete before resuming daily life; it involves separating from the deceased, adjusting to a world without them and forming new relationships.

People grieve not only for the deceased, but also for the unfulfilled dreams and plans for the future that they hoped to share with them.

Phases of grief

Grief usually passes through three stages, but these stages are not separate, nor do they necessarily follow in sequence.

An initial stage of shock or disbelief when it is difficult to believe that the death has occurred. This stage may last minutes or weeks.

A stage of acute anguish that usually lasts from weeks to months when feelings of depression occur; planning the future may be difficult.

A phase of resolution after months, or even years.

What is normal grief?

This is a term used to describe the typical symptoms somebody experiences after bereavement. It can include:

disbelief, shock, numbness and feelings of unreality

anger

feelings of guilt

sadness and tearfulness

preoccupation with the deceased

disturbed sleep and appetite and, occasionally, weight loss

seeing or hearing the voice of the deceased.

The initial disturbance the above symptoms causes is gradually reduced and people begin to accept the loss and readjust.

A grief reaction can last for up to 12 months, but can vary within different cultures. The average is probably around six months. A resurgence of symptoms can also occur briefly on anniversaries of the bereavement and on birthdays, etc of the deceased.

Depression and grief

Grief and depression are different. It is possible to grieve without being depressed, but many of the feelings are similar.

However, about 33 per cent of bereaved people also have a depressive illness one month after the loss, and 15 per cent are still depressed a year later.

Symptoms that suggest a bereaved person is also depressed include:

intense feelings of guilt not related to the bereavement.

thoughts of suicide or a preoccupation with dying.

feelings of worthlessness.

markedly slow speech and movements, lying in bed doing nothing all day.

prolonged or severe inability to function (not able to work, socialise or enjoy any leisure activity).

prolonged hallucinations of the deceased, or hallucinations unrelated to the bereavement.

Who is likely to get depression after a bereavement?

It is difficult to judge who will or won't suffer depression after a bereavement. However, risk factors thought to increase the chance include the following:

a previous history of depression

intense grief or depressive symptoms early in the grief reaction

few social supports

little experience of death.

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