Linda Gask1 and Carolyn Chew-Graham2
1 University of Manchester, Manchester, UK
2 Research Institute, Primary Care and Health Sciences and National School for Primary Care Research, Keele University, Keele, UK
Grief is a universal human experience following the loss of someone or something that is important to a person. It is sometimes confused with depression but may coexist with it. In discussing depression and anxiety, we need to clarify exactly what grief is and how and when it should be treated.
Different terms are used, in everyday life as well as in the literature, to describe the experiences and tasks involved. We find the following definitions useful:
We never ‘get over’ the death of a person who meant a great deal to us, but we learn how to live with the reality of it.
Our relationships with people around us help to give our lives meaning, and are a source of support and pleasure.
Acute grief is extremely distressing and a time of intense and painful feelings. At first there may be a sense of disbelief and shock but this is followed by a range of different emotions (see Box 7.1). The acute period of grief can be difficult to distinguish from depression (see below).
Over time, the intensity of the emotion begins to lessen. What is important to remember is that there is no universal rule about which ‘stages’ of grief the person will pass through and in what order. Five stages were famously described by Elisabeth Kübler-Ross: denial, anger, bargaining, depression and acceptance – but not everyone experiences these, and they were actually observed in people who were coming to terms with their own impending death (another form of loss), rather than the death of another. There is also no rule about how long it takes to pass through the acute stage of grief, certainly not the rule of ‘3 months’ often cited in healthcare settings. The DSM-5 criteria allow for a diagnosis of depression just 2 weeks after a bereavement, and have been widely criticised as being over-simplistic and leading to the over-medicalising of a normal response to loss. Practitioners should appreciate key is the trajectory is towards lessening of the intensity of the grief as the weeks and months pass, and with time, a gradual moving towards re-engagement with what is going on in everyday life. Positive memories of the deceased can be recalled, and new memories can be incorporated into how we remember them.
Jess (see Box 7.2) is experiencing many of the features of acute grief following the death of her mother. She is able to gain some benefit from talking with her boyfriend about how she is feeling, but she also goes to see her GP.
It is important that Jess is supported in being able to mourn for her mother. Her GP reassures her and explains to her that the symptoms she is experiencing are normal and natural following bereavement. The GP listens to Jess talk about what happened to her mother and is alert to the things that might derail Jess’s mourning such as dwelling too much on her negative feelings of guilt, gently challenging her views about whether she could realistically have done more for her mother. She checks that Jess is moving on in her grief by arranging to see her again a month later, and finds that Jess is beginning to take an interest in her studies again. She encourages Jess to talk about the good memories of her life with her mother and the positive ways in which her life can be remembered. The GP suggests that Jess might look up details of CRUSE on the internet, or seek further support from the university counselling service.
A small proportion of people who are bereaved, less than 10%, fail to grieve normally. People with ‘complicated grief’ show the features in Box 7.3.
Sometimes mourning does not begin and a bereaved person remains in a state of disbelief and shock regarding the death. On other occasions, the stage of acute grief may be short or the person may seem to function quite normally as mourning doesn’t begin or seems to be suddenly curtailed. The bereaved person may, for example, be distracted by having to deal with family problems that arise following the death or in sorting out complicated legal matters relating to the death. The normal grieving process may thus be delayed and then triggered again (sometimes even years later) by a subsequent loss or by an event that powerfully brings back memories and reminds them of the loss. A further group of people may begin to grieve, but then remain very distressed, with this sometimes increasing in intensity with time; or the intensity may simply remain exactly as it was immediately after the death. Sometimes in such cases the personal belongings or room of the person who has died remain untouched, in waiting for their return. All of these patterns differ from ‘normal’ grief, where the intensity of the emotion experienced gradually lessens over time – even if this is over a period of years. Abnormal grief is more likely in the circumstances shown in Box 7.4.
People with complicated grief have been found to be at increased risk for cancer, cardiac disease, hypertension, substance misuse and suicide.
Bridie, in Box 7.5, is experiencing an abnormal grief reaction. The intensity of her distress is increasing, and she is exhibiting several of the features in Box 7.3. With time, however, she also seems to be increasingly low in mood, and the GP needs to be alert to the development of depression and risk of self-harm.
Bereavement can trigger the onset or worsening of previous mental or physical health problems. About 30% of people who are bereaved go on to experience depression, and those with a personal or family history are most at risk. It is important not to mistake acute grief for major depression, but to monitor the progression of mourning in a person at increased risk for depression. If there is an increasing intensity and severity of low mood and clear presence of persistent symptoms of depression it may be necessary to treat the depression. This may also be necessary in prolonged abnormal grief if/when symptoms of depression begin to dominate the clinical picture, as is the case with Bridie. Bereaved people who are also experiencing depression may experience symptoms such as lack of energy, negatively biased thoughts and inhibition of positive emotions that interfere with their ability to move on in their grief and reconnect with life. There is no rigid time frame for this such as ‘after three months’. Severe depression may become apparent well before this. In deciding whether to treat for depression it is necessary to continue to assess the progress of grieving and the emerging clinical picture.
This can be difficult; the bereaved person may feel that ‘treatment’ is not needed as they do not wish to stop thinking about the deceased and that any attempt at therapy is trying to separate them from the dead person in some way. It usually requires referral to specialist psychological therapy. However, some basic principles can be outlined:
Bridie’s GP listens to her talk about how she is feeling and realises that Bridie is not only grieving abnormally but is becoming more depressed and anxious. She is particularly concerned about Bridie’s ideas of wanting to be with Jed and Frank. She gently explores whether Bridie has had any thoughts of wanting to take her own life. Bridie says she has thought about this, in order to join her sons in heaven, but her beliefs as a Roman Catholic prevent her from carrying this out as she thinks this would be sinful. Her doctor discusses with her the possibility of starting her on an antidepressant in order to help with the symptoms of depression. She also begins, at the same time as continuing to listen and empathise with Bridie’s loss, to encourage her to set simple goals for re-engaging with everyday life, starting with simple tasks such as eating regular meals, and moving on to going out to see friends again. Bridie’s mood improves slowly. She spends less time looking at photographs and more time again with her family, although she continues to have periods when she is very sad. Complicated grief takes a long time to resolve, and sometimes becomes chronic. It is important to try to help the bereaved person to engage again with everyday life whilst at the same time providing empathetic listening and support. Where depression is clearly present it should be treated.
Bereavement can lead to a normal grief response. It is only when a person gets stuck in one step for a long period of time that the grieving can become unhealthy, destructive and even dangerous. Going through the grieving process is not the same for everyone, but everyone does have a common goal – acceptance of the loss and to keep moving forward. The process is different for every person and the support of a GP with time to listen and monitor can ensure that complicated grief or depression are identified early and appropriate treatment offered.