What is grief, what is prolonged grief and what is depression?
There is no simple definition of normal grief, but some main points can be noted. Grief after the death of a loved one includes a number of different reactions that are of an affective, cognitive, behavioural and somatic nature (4). There are major individual differences in how people react and adapt to the loss of a loved one. This depends on a number of factors such as who has been lost, the closeness in the relationship, the way in which the death occurred, the support provided by others, and personality factors (5).
Grief often comes in waves, with sudden, intense reactions (pangs of grief) that can be triggered by internal or external reminders. At a relatively early stage after a loss, many bereaved persons may experience positive emotions in addition to the painful grief, for example when talking about happy memories or relating anecdotes from the life of the deceased (1). With time, the waves of grief will come more rarely, and the sadness and feelings of unreality will gradually recede, although large and dramatic losses, such as the loss of a child and loss caused by sudden, violent death will often progress differently from losses that could be expected (6). Grief reactions often intensify around anniversaries and holidays.
Prolonged grief is the most common form of complicated grief in adults (5). It is different from normal grief in that the immediate grief reactions persist over time with more or less undiminished strength, causing a considerable loss of everyday functioning (2). One may also observe little change or flexibility with regard to the way in which this grief is handled (2, 4).
Prolonged grief is primarily characterised by an intense longing for or persistent preoccupation with the deceased person (2, 3). Other characteristics include difficulties in accepting the death, the feeling of having lost a part of oneself, difficulties in continuing with life, emotional numbness and avoidance of things/places/activities that serve as reminders of the deceased. Others also emphasise rumination over how the death could have been avoided, blaming of others and self-blame as typical of persons who struggle with prolonged grief (2).
While many laypersons and professionals would say that normal grief lasts through the first year until all major anniversaries have passed, the proposal in ICD-11 states that prolonged grief can be diagnosed six months after the bereavement (3). The intensity and duration of the grief reactions must go beyond what is expected in light of cultural and religious norms. Studies indicate that approximately 7 % of those who lose someone to death are affected by prolonged grief (2), but far higher figures have been found among parents who have lost a child and those who have been bereaved through sudden, violent death (6). It is important to point out that grief can be intense and last for more than six months without automatically being deemed abnormal. The central issue in prolonged grief is its considerable impact on daily functioning.
Depression is a heterogeneous diagnostic group and among the most common mental afflictions that we know (7). It is estimated that 6 – 12 % of the Norwegian population suffer from depression at any one time (8). The most common symptoms include low mood and lack of interest in and enjoyment of normal activities, as well as fatigue and reduced energy (9). In addition, difficulty in concentrating, poor self-esteem, self-accusations or feelings of guilt, hopelessness, suicidal thoughts, sleep disturbances and loss of appetite, as well as psychomotor agitation or retardation are common. Depressions are frequently graded into mild, moderate and severe forms, and the symptoms must have persisted for more than two weeks before a diagnosis can be made (9).
Loss of a loved one through death is a known risk factor for development of depression (1). International studies have shown that approximately 15 % of all widows/widowers suffer from depression one year after the loss of their spouse, and approximately 12 % two years later (1). The figures vary depending on who has been lost and the circumstances in which the loss occurred. A Norwegian study shows that 25 % of the bereaved who survived the tsunami disaster in 2004 suffered from depression two years after the incident (10). Furthermore, studies show that up to 50 – 70 % of those who endure prolonged grief also suffer from depression (1). Having had depression prior to a death increases the risk of developing both depression and prolonged grief after the loss of a loved one (1).