Differentiating Grief and Depression in Seriously Ill Patients

Almost all seriously ill patients experience grief when confronted by the losses and limitations imposed by the illness. Grief is a reaction to any loss. As Freud¹ observed, grief is “the reaction to the loss of a loved person or to the loss of some abstraction which has taken the place of one, such as one's liberty…” Grief manifests as emotional, social, spiritual, physical, cognitive and behavioral changes through which a person attempts to reorganize and resolve or adjust to the loss at his or her own pace^{2, 3}. In contrast, depression is neither a universal phenomenon nor normal in seriously ill patients⁴. Differentiating between grief and depression is important as the management strategies for each is different. To note, the grief experienced by patients as they grapple with their serious illness and personal death awareness is different from anticipatory grief as defined by the extensive body of existing literature (the terms anticipatory grief and anticipatory mourning are commonly used to refer to grief experienced by family members or friends before the anticipated death of a loved one).

Differentiating between grief and depression is challenging in a seriously ill patient population as both have overlapping symptoms (sadness, crying, loss of appetite, weight, sleep etc.) and may co-exist^5,6. Thus affective and somatic symptoms are typically unhelpful in identifying depression in seriously ill patients. Instead, cognitive manifestations of depression like anhedonia (loss of pleasure) hopelessness, worthlessness, loss of self-esteem, active and persistent desire for an early death and persistent dysphoria are hallmarks of depression in seriously ill patients. There is a prevalent myth that all seriously ill patients lose pleasure in everything and that they are devoid of hope. In fact, most seriously ill patients work hard to reconcile with the fact that they have a potentially limited life span, re-establish a new equilibrium that incorporates the knowledge of life with a serious illness and try to make the most of the remaining time. In fact many find joy is spending time with their loved ones in addition to still enjoying the simple pleasures of life (One of my patients who was dying of cancer was mother with a young daughter and was intensely grieving the fact that she would not be alive to raise her daughter. However, she always look forward to and greatly enjoyed my visits when I took her a slice of hot apple pie with a scoop of her favorite vanilla ice-cream and sat down to help her plan for completing some of her life goals). Also, as patients progress through the trajectory of serious illness, hope shifts. Hope for a cure may change to hope for better symptom control or hope for reconciliation with estranged loved ones. Loss of hope is thus an excellent clue of underlying depression. Approximately, one in five seriously ill patients are likely depressed. Early identification and aggressive management of depression with a combination of pharmacological and non-pharmacological modalities is effective and alleviates suffering in these patients.

In this issue of American family Physician (see page ____), Widera and colleagues discuss the presentation and management of grief and depression at the end of life and suggest that majority of individuals who are grieving cope with their distress without involving health care professionals and that clinicians can help those grieving by encouraging patients to use of external sources of support. The acronym RELIEVER as described below can serve as a reminder about supportive interventions that can facilitate preparatory grief and such facilitation can be done both by trained clinicians as well as the patients' family and friends.

Facilitating grief in seriously ill patients
Task	How to do this
Reflect	Reflecting or mirroring the patient's feeling by naming and summarizing the underlying emotion in a safe and gentle way
	Example: If the patient says, “Why did I to get this horrible disease?” respond with “I can see that you are angry”.
Empathize	Empathy is defined as the intellectual identification with or vicarious experiencing of the feelings, thoughts, or attitudes of another.
	Example: “It must be really hard for a very independent person like you to accept help. I really admire how gracious you are being about this.”
Lead	Guided questions can help facilitate the grief process.
	Example: “As you looking ahead and planning for the time ahead, what concerns you the most?”
Improvise	A grieving patient's mood often fluctuates over time. Sometimes, the patient may be full of hope and optimism and manifest restoration oriented grief. At others, the patient may be sorrowful and manifest loss oriented grief. It is important to first gauge the patient's current mood and offer support that is congruent to the current emotional state of the patient. Some patients may want to process their grief by recounting their past or recent experiences and active listening is helpful in these situations. Others may want just a quiet and supportive presence and prefer to remain in companionable silence. To note, patients may suddenly change coping strategies, which requires flexibility on the part of the clinician to be able to respond appropriately.
Educate	Explain to the patient that grief ebbs and flows. Ensure that the patient and family understand that people grieve in different ways and that anger, yearning, sadness are all common manifestations of grief. Similarly, family members may manifest their anticipatory grief as anxiety or anger towards the patient. Identifying, validating and channeling constructive outlets for anger helps decrease conflicts between patients and their families.
Validate the Experience	Many patients often report that they feel like they are on an emotional roller-coaster as they struggle to cope with the serious illness. Validate the normalcy of the experience and support them through the process. Example: “It seems to me you are responding normally to a very difficult situation” or “These mood swings are very common when coping with a serious illness”
Recall	Many patients who are seriously ill often do a life review and reflect on their past accomplishments and disappointments. Clinicians can help by asking about personal accomplishments, special stories or legacies that patients may wish to hand down to future generations.