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Fast Fact and Concept #43: Is it Grief or Depression

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Title: Fast Fact and Concept #43: Is it Grief or Depression

Author(s): VJ Periyakoil

HR is a 70-year-old male dying of a metastatic carcinoma. His pain is well controlled. However, he has a very poor appetite ,is losing weight and has frequent crying spells. He occasionally expresses a wish to die and 'get it over with'. Is he grieving or depressed?

DEFINITIONS

PREPARATORY (AKA ANTICIPATORY) GRIEF: is the grief, "that the terminally ill patient has to undergo in order to prepare himself for his final separation from this world"1. Features, include rumination about the past, withdrawal from family/friends and periods of sadness, crying or anxiety. It is important to note that Preparatory Grief is a normal, not pathological, life cycle event.

DEPRESSION: Clinically significant depression among a population of dying patients may be somewhat more common (25-77%)2 than in the general population. However, depression is not an inevitable part of the dying experience and is very treatable. Somatic symptoms (anorexia, weight changes, constipation etc) are often present as a part of the normal dying process and may not help to distinguish between preparatory grief and depression. Feelings of guilt, hopelessness, worthlessness, and suicidal ideation are the key factors that differentiate grief from depression. When in doubt, it is recommended to treat for depression (see future Fast Fact on treatment options). The following additional points are offered to help the clinician distinguish between preparatory grief and depression.

DISTINGUISHING PREPARATORY GRIEF vs. DEPRESSION

TEMPORAL VARIATION
A temporal variation of mood is normal in preparatory grief-a mixture of "good and bad days". In contrast, persistent flat affect or dysphoria is characteristic of depression. Depression is a pathological state; patients may "get stuck" in this state without treatment.

SELF IMAGE
A disturbed self-esteem is not typically seen in grief while this is a common feature of depression; overwhelming and persistent feelings of worthlessness to others and of being a burden are common in depression. Distressing guilt in usually generalized to all facets of life in depression, while in grief, the guilt is focused around specific issues (e.g. not being able to attend a child's wedding).

HOPE
A grieving patient's hope shifts, but is not lost. (Hope may shift from a hope for cure to hope for life prolongation to hope for dying well). In contrast, the depressed patient will comment on feelings of hopelessness and helplessness.

ANHEDONIA
The ability to feel pleasure is not lost in preparatory grief. Note: grieving patients often need social interaction to help them through the grief process. Anhedonia is an important clue to underlying depression.

RESPONSE TO SUPPORT
Social support helps provide the acceptance and assistance necessary for completion of grief work3. While social interaction may be helpful in some depressed patients, it will typically not provide the assistance necessary to resolve depression.

ACTIVE DESIRE FOR AN EARLY DEATH While suffering associated with uncontrolled symptoms such as pain, concern over being a burden and a desire to be in control of one's dying, may all result in thoughts of an earlier death, an active desire for an early death is not typical of preparatory grief. A persistent, active desire for an early death in a patient, whose symptomatic and social needs have been reasonably met, is suggestive of clinical depression4.

Also See:
Fast Fact #32: Grief and Bereavement (Part I)

References

Kubler-Ross E. On Death and Dying: 123-124; New York, NY:Simon and Schuster, 1997.

EPEC Project Module 6: Anxiety, Delirium, Depression; AMA, 1999.

Rando TA.: Grief, Dying, and Death. Clinical Interventions for the Caregiver. Research Press Company, Champaign, Illinois, 1984.

Chochinov HM, et al. Desire for death in the terminally ill. Am J of Psychiatry, 1995:152:1185-91.

Billings A and Block S. Depression. J Pall Care 1995, 11:48-54.2

Block, SD., for the ACP-ASIM End-of-Life Care Consensus Panel. Assessing and managing depression in the terminally ill patient. Annals Intern Med 2000;132:209-218.

Copyright Notice: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Periyakoil, VJ. Fast Facts and Concepts #43: Is it grief or depression? June, 2001. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Fast Facts and Concepts was originally developed as an end-of-life teaching tool by Eric Warm, MD, U. Cincinnati, Department of Medicine. See: Warm, E. Improving EOL care--internal medicine curriculum project. J Pall Med 1999; 2: 339-340.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 6/2001

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)
Training: Fellows, 1st/2nd Year Medical Students, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery
Non-Physician: Clergy/Chaplains, General Public, Graduate Students, Lawyers, Patients/Families, Nurses, Social Workers

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Grief/bereavement, Psychiatric


The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).