Background   Distinguishing between a dying patient’s normal grief and a major depression is a part of routine care for patients near the end-of-life.  This Fast Fact will review the definitions and clinical features that distinguish these conditions.  See Fast Facts #7, #32, and #254 for further discussions of depression, grief, and complicated grief.

Definitions

• Preparatory (or anticipatory) grief.  This 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.  Preparatory Grief is a normal, not pathological, life cycle event.
• Depression. Clinically significant depression in a population of dying patients is likely somewhat more common (25-77%) than in the general population (2). However, depression is not an inevitable part of the dying experience and is 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, treat for depression.  Utilize mental health professionals when available.  The following additional points are offered to help the clinician distinguish between preparatory grief and depression.

Distinguishing preparatory grief from 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 can ‘get stuck’ in this state without treatment. Self-Image.   A disturbed self-esteem is not typically seen in grief; however it 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 is 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 work (3). 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.   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 depression (4).

·Self-Image.   A disturbed self-esteem is not typically seen in grief; however it 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 is 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).

References

1. Kubler-Ross E. On Death and Dying. New York, NY: Simon and Schuster; 1997: pp123-124.
2. EPEC Project Module 6: Anxiety, Delirium, Depression. In: Emanuel LL, von Gunten CF, Ferris FF, eds.  The EPEC Curriculum:  Education for Physicians on End-of-life Care. Chicago, IL: The EPEC Project; 1999.  http://www.EPEC.net.
3.  Education on Palliative and End-of-Life Care.  http://www.epec.net. 1999. 
4. Rando TA. Grief, Dying, and Death. Clinical Interventions for the Caregiver. Champaign, IL: Research Press Company; 1984.
5. Chochinov HM, et al. Desire for death in the terminally ill. Am J of Psychiatry. 1995; 152:1185-91.
6. Billings JA, Block SD. Depression. J Pall Care. 1995; 11:48-54.
7. 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.
8. Block SD. Psychological considerations, growth, and transcendence at the end of life: the art of the possible.  JAMA. 2001; 285:2898-905.

Version History: This Fast Fact was originally edited by David E Weissman MD.   2nd Edition published August 2005; 3rd Edition May 2015. Current version re-copy-edited April 2009; then again May 2015.