BEREAVEMENT AND DEPRESSION

Bereavement is one of the most painful experiences in life, one for which there is no way to prepare, or to predict its effect. Bereavement is a category that is well described in DSM-IV, but for the average person it is not usually associated with clinical depression. A diagnosis of depression may be considered if the physician considers that their patient is experiencing difficulty with severe and prolonged depression following a loss.

Bereavement presents a somewhat unique look at the expression of depression. As part of their reaction to the loss of a loved one, some people experience symptoms of major depressive disorder, including continuing feelings of sadness, apathy, loss of appetite, sleep disturbances, and weight loss. Depressed mood to a certain degree is an expected effect of the loss of a loved one, and may be indistinguishable in its depth from major depressive disorder in the absence of bereavement. It is generally expected that eventually the depression will begin to lessen, and that it will do so without the benefit of professional medical help.

Primary care physicians are most likely to see the bereaved patient not for relief from their depressed feelings, but for one of a number of associated physical symptoms, such as lack of appetite, headache, or insomnia.

Bereavement and depression are particular concerns in older people, partly because they may be losing a number of loved ones or friends in a short period of time, and they may, due to illness or lack of resources, be poorly equipped to deal with an emotional shock. In older men and women, studies have revealed that the experience of grief persists for at least 30 months in those who have lost their spouse, and women report more depression (but not grief) than men.

Bereavement in a child - the loss of a parent or other significant loved one at an early age - is a recognized stressor that can be implicated in the development of depression. Children and young people may experience bereavement in a different way than adults; for example, their sense of time is different, and they may resolve their grief much more quickly.

A relatively recent and distinct circumstance in bereavement and depression exists in the gay community, where AIDS deaths represent a significant and perpetual reality for friends and family.

The experience of depression and its duration after a loss is interpreted differently in different cultures. In general, a diagnosis of depression is not considered until the depressive symptoms have existed for more than 2 months; however, it is recognized that recovery from a major loss can take one to two years. This poses a diagnostic difficulty for the physician. A number of symptoms that are not associated with normal grief, but are criteria for a diagnosis of depression (e.g., guilt, extreme psychomotor retardation) may be present, that will help the physician to distinguish depression associated with bereavement. Another difference between bereavement and depression is that generally, the bereaved person is able to continue daily activities, while the depressed person is not.

Bereavement is considered a risk factor for the development of depression, with spousal bereavement one of the most disruptive of naturally occurring stressors. Critical life events such as this can effect the brain's neurotransmitters and contribute to both the psychological and physical symptoms of depression. Studies have found that complicated bereavement - which may include factors such as unexpectedness of the loss, a conviction that one will never get over the loss, absence of support and multiple losses or illnesses in the same time period - does warrant treatment.

Please see:

Section IV: "Managing Other Depressive Disorders"
CANMAT – Guidelines for the Diagnosis and Pharmacological Treatment of Depression
(1st Edition Rev., 1999)
P. 32

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