Although grief knows no boundaries in terms of age, if we are fortunate to live decades then we will unfortunately experience grief. It is part of being human. Like other aspects of life such as giving birth, how do we know when these normal processes require more than the usual assistance? How do we know when grief has morphed into a serious depression requiring medical help?

The differences between normal grief and major depression can be difficult to understand or tease apart because they have overlapping experiences. Great sadness, loss of appetite, difficulty focusing, and inability to sleep can all be part of either process. It is the subtle but powerful differences that can determine when a person is in need of additional help beyond that which is given by family, friends and clerics.

There are cultural differences in the expression of grief. Griefspeaks.com discusses the dissimilar responses varying groups of people have toward death. These differences express themselves not only in the traditions of burial or cremation, but also in ceremonial markers. Jewish observances, for example, may include an unveiling of the tombstone at the year anniversary date of the death of a loved one.

Some groups support a restrained expression of grief, while for others the act of intense lamenting is expected. Some people believe the dead to be present, and others believe in the possibility of reincarnation. The Day of the Dead celebrated by many Latin Americans in the U.S. and throughout Mexico involves communicating through prayers and speaking with those who have perished. The spirits of the deceased are invited to be present for this observance.


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There are clearly cultural and individual differences in the act of grieving, so how does one know when someone is having symptoms needing professional intervention? In "Grief, Depression, and the DSM-5," Rochelle Perper, Ph.D., describes "typical grief," and major depression. She also describes "complicated grief" such as that associated with the death of a child, a traumatic death, or other circumstances adding to the distress of the loss.

Grief that is common to all of us has some identifiable markers. Several articles describe it as coming in waves of great sadness interspersed with lighter moments occurring when consoled or experiencing thoughts of pleasant memories. Perper describes desiring to be alone in natural grief as common, but so is the yearning for "emotional connection with others." In common grief, some people wish to die as a means of connecting with their lost loved ones. Nonetheless there is a sense of hopefulness and a belief that the intensity of the grief will pass, while a sense of self-worth remains.

When major depression is prompted by grief or when grief is added to existing depression, people cannot see or believe in an end to their suffering. They have an almost constant feeling of doom, accompanied by paralyzing low self-regard. Some reach the point of having thoughts of not deserving to live or of suicide. People with major depression can be comfortless and far from the reaches of rational reassurance. Added to their burden, they are not able to connect with pleasant memories of the person who has died.

Grief is a normal and painful process for most people. Yet there are times when the suffering of grief slides into an intractable abyss, which is how depression became known as the "black dog." There are times when typical supports have worn thin, and nothing anyone says or does is experienced as helpful. It is under such circumstances medical help is needed, which may include therapy and medication.

A family or individual history of depression can be an indicator of the need to seek help in the presence of grief. Treating major depression in the company of grief doesn't interfere with feeling the pain of loss or of love for the person who has died, but rather allows the process of grief to be more fluid. In this way one is able to connect with the harshness of the loss while understanding they will feel better in time. Just as in pregnancies where medical assistance is needed under certain circumstances to save the mother or baby or both, getting medical help for grief that is complicated by signs and symptoms of major depression can also be a lifesaving event.

Carolyn Sacco, RN, has worked as a nurse in psychiatry since 1985, in inpatient hospital, outpatient clinic, and home settings. Jeffrey Geller, MD. MPH, is professor of psychiatry at the University of Massachusetts Medical School. He also treats in- and outpatients.